CASE REPORT

DIABETES MELLITUS WITH DYSPEPSIA

By :
Jihanita Diansabila (2015730066)

Preceptor :
dr. Ihsanil Husna, Sp.PD, FINASIM

MEDICAL PROFESSION PROGRAMME DEPARTMENT OF

INTERNAL MEDICINE
JAKARTA ISLAMIC HOSPITAL CEMPAKA PUTIH
FACULTY OF MEDICINE UNIVERSITY OF MUHAMMADIYAH
JAKARTA
2020
 PREFACE

AssalamualaikumWr. Wb.
Alhamdulillah, All praise to Allah SWT the almighty and the most merciful.
Shalawat and salaam to Rasulullah Muhammad Peace be Upon Him which bring us
from the darkest of time into the lights.
The writer also wish to express his deep and sincere gratitude for those who
have guided in completing this case report paper to fulfill the criteria for completing
Medical Profession Programme in Internal Medicine Department of Jakarta Islamic
Hospital Cempaka Putih, Faculty of Medicine University of Muhammadiyah Jakarta.
The writer wish this paper to be useful and add another dimension of knowledge
for the writer himself, medical profession student, and anyone else who never stop in
learning.
The writer acknowledge in the process of making this paper, there are a lot of
mistake and far from perfect, cause perfection are only belong to Allah SWT. All the
critics and advice are needed for the writer for the better of ourselves in this journey to
be the long life learner.
Previously thank you to dr. Ihsanil Husna, Sp.PD, FINASIM who had the
opportunity to attend the guidance this time. In here, I will present a presentation about
case report. With all pleasure.

WassalamualaikumWr. Wb

Jakarta, February 22, 2020

Jihanita Diansabila
 CHAPTER I
PATIENT’S STATUS

A. Patient’s Identity
Name : Mr. S

Age : 62 years old

Addres : Pamendangan, North Jakarta

Marital Status : Married

Religion : Moslem

Race : Betawi

Medical Record : 00047xxx

Date of Admission : February, 18th 2020

Date of Examination : February, 20nd 2020

B. Anamnesis
a. Chief Complaint
Nausea and vomiting since 1 day before being admitted to the hospital.
b. Another Complaint
Fatigue
c. History of Present Illness
The patient complained of nausea and vomiting since 1 day before being
admitted to the hospital. Patient threw up 3 times/day. Patient got an
intermittent epigastric pain since 2 months ago. Patients felt so weak 3 days
 before he came to the hospital. It happened to the whole body after doing
the activity, and continuously heavier day by day, and it showed impairment
daily activities. Patient said that he has a history of heart disease and
diabetes mellitus.
d. History of Past Illness
• History of Type 2 Diabetes Mellitus
• History of Heart Disease
e. History of Family
History of Type 2 Diabetes Mellitus
f. History of Allergy
No history of drugs or foods allergic
g. History of Treatment
The patient had metformin 500 mg tab
Medication for heart disease
h. History of Psychosicial
Patient smoker active 10 years ago, but not alcoholism, or drug abuse.

C. Physical Examination
Generalis Status : Moderate ill

Consciusness : Compos mentis (E4V5M6)

Vital Sign

• Blood Pressure : 120/70 mmHg

• Pulse : 90 x/minute

• Respiratory rate : 20 x/minute

• Temperature : 36,6oC
Anthropometric Status

• Body weight : 55 kg

• Body high : 158 cm

• BMI : 22 (Normoweight)

General Physical Examination

• Head : Normocephal

• Eye : Anemic conjungtiva (-/-), icteric sclera (+/+), light reflex

(+/+)

• Nose : Normonasi (+), secret (-/-), epistaksis (-/-), hyperemic

mucosa (-/-)

• Ear : Normotia, secret (-/-)

• Mouth : Oral mucose moist, cyanosis (-), coated tongue (-)

• Neck : Lymph node enlargement (-), tyroid enlargment (-),

JVP (-)

Thorax

• Inspection : The movement of the chest symmetrical

• Palpation : Same vocal fremitus in dextra and sinistra

• Percussion : Sonor

• Auscultacion : Vesicular breath sounds + / +, Ronkhi -/-,

Wheezing - / -

Cor
 • Inspection : Ictus cordis not seen in ICS V LMCS

• Palpation : Ictus cordis not palpable ICS V LMCS

• Percussion : Right heart margin: Sternalis line sinistra ICS-V

Left heart margin: Midclavicula line sinistra ICS-V

• Auscultacion : Regular 1st & 2nd heart sounds, Murmur (-), Gallop (-)

Abdomen

• Inspection : Flat, scar (-), abdominal distension (-), darm contour

(-), darm steifung (-)

• Auscultacion : Bowel Sound (+)

• Palpation : Epigastric pain (+), hepatomegaly (-), spleenomegaly (-)

• Percussion : Dullness in the lowest part of the stomach. Other region

are tympanic.

Extremities

• Superior : Edema (- / -), warm acral (+ / +), RCT ≤ 2 seconds (+ /

+), cyanosis (-/-), petechia (-/-)

• Inferior : Edema (+ / +), warm acral (+ / +), RCT ≤ 2 seconds (+ /

+), cyanosis (-/-), petechia (-/-)

D. Laboratory examination
February, 18th 2020 01:30 p.m

EXAMINATION VALUE UNITS NORMAL

Hematology
Hemoglobin 12,6 g/dL 13,2 – 17,3
Hematocrit 35 % 40 – 52
Leukocyte 12,11 103/uL 3.8 – 10,6
Thrombocyte 164 103/µl 150 – 440
Erythrocytes 4,34 106/µl 4,4 – 5,9
MCV 81 Fl 80-100
MCH 29 Pg 26-34
MCHC 36 g/dl 32-36
Kidney Function
Creatinine 4,4 mg/dL <1,4

Electrolytes
Sodium (Na) 127 mEq/L 135-147
Potassium (K) 3,8 mEq/L 3,5-5,0
Chloride (Cl) 96 mEq/L 94-111
Diabetes
Blood Glucose 236 mg/dL 70-200
 Laboratory Findings : 19/02/2020

- Blood Glucose 165 mg/dL (06.00)

- Blood Glucose 143 mg/dL (11.00)

- Blood Glucose 257 (17.00)

Laboratory Findings : 20/02/2020

- Blood Glucose 222 mg/dL (11.00)

- Blood Glucose 180 mg/dL (17.00)

E. Resume
Mr. S, 62 years old, The patient complained of nausea and vomiting since 1
day before being admitted to the hospital. Patient threw up 3 times/day. Patient
got an intermittent epigastric pain since 2 months ago. Patients felt so weak 3 days
before he came to the hospital. It happened to the whole body after doing the
activity, and continuously heavier day by day, and it showed impairment daily
activities. Patient said that he has a history of heart disease and diabetes mellitus.
The patient is under treatment of heart disease and diabetes mellitus.

Physical Examination:

Moderate ill, composmentis (GCS: 15), epigastrium pain (+).

Vital Sign :

• Blood Pressure : 120/70 mmHg • Heart Rate : 90x/minute

• Respiratory Rate: 20x/minute • Temperature: 36,6°C

Laboratory Findings :

• Hematocrite : 35% • Leukocyte : 12,11 103/uL

 • Creatinine 4,4 mg/dL • Blood Glucose 236 mg/dL

Sodium

• (Na) 127 mEq/L

F. Problem List
• Malaise

• Nausea

• Vomit

• Leucocytosis

• Hyperglicemia

G. Assessment
1. Nausea + vomitus + malaise e.c Dyspepsia dd/ Gastritis

SUBJECTIVE :
The patient complained of nausea and vomiting since 1 day before being
admitted to the hospital.

OBJECTIVE :

Vital Sign: BP: 120/70 mmHg, HR:90x/minute, RR:20x/minute, Temperature:

36,6°C.

Physical Examination : Epigastric pain (+)

Laboratory Findings :

18/02/20

• Hematocrite 35%

• Leukocyte 12,11 103/uL

 • Creatinine 4,4 mg/dL Sodium

• (Na) 127 mEq/L

• Blood Glucose 236 mg/dL

ASSESMENT :

Nausea + vomitus + malaise e.c Dyspepsia dd/ Gastritis

PLANNING :

• Diagnostic

Urea Breath Test, OGD

• Planning Non Therapeutics

Offer simple lifestyle advice, including advice on healthy eating, weight

reduction and smoking cessation, alcohol, coffee, chocolate, fatty foods and
being overweight. Raising the head of the bed and having a main meal well
before going to bed (may help some people).

• Planning Therapeutics

• IVFD RL 500 cc / 8 hours

• Lansoprazole 30 mg / day

• Ranitidin inj 1 amp

2. Hyperglicemia + malaise e.c type 2 diabetes mellitus

SUBJECTIVE :

Patients also complained of weakness since 3 days before entered the hospital.
It happened the whole body after doing the activity, and continuously heavier
day by day, and it showed impairment daily activities.
OBJECTIVE :

Vital Sign: BP: 120/70 mmHg, HR:90x/minute, RR:20x/minute, Temperature:

36,6°C.

Physical Examination : Epigastric pain (+)

Laboratory Findings :

18/02/20

 Hematocrite 35%

 Leukocyte 12,11 103/uL

 Creatinine 4,4 mg/dL Sodium

 (Na) 127 mEq/L

 Blood Glucose 236 mg/dL

19/02/2020

 Blood Glucose 165 mg/dL (06.00)

 Blood Glucose 143 mg/dL (11.00)

 Blood Glucose 257 (17.00)

20/02/2020

 Blood Glucose 222 mg/dL (11.00)

 Blood Glucose 180 mg/dL (17.00)

ASSESMENT :

Hyperglicemia + malaise e.c type 2 diabetes mellitus

PLANNING :
 Diagnostic

HbA1c, FPG

Planning Non Therapeutics

Lifestyle Intervention, nutrition, physical activity, tobacco use.

Planning Therapeutics

Metformin 500 mg tab

H. Follow Up Patient

Tuesday, February 18 2020

S Nausea and vomit. Patient felt weakness the whole body. History of type 2
diabetes mellitus and heart disease.
O Vital Sign
BP : 100/70 mmHg
HR : 78 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (+)
Laboratory Findings : 18/02/2020
- Hematocrite 35%
- Leukocyte 12,11 103/uL
- Creatinine 4,4 mg/dL Sodium
- (Na) 127 mEq/L
- Blood Glucose 236 mg/dL
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Ranitidine inj 1 amp
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy
Wednesday, February 19 2020
S Nausea and vomit less than yesterday. No more weakness. History of type 2
diabetes mellitus and heart disease.
O Vital Sign
BP : 130/80 mmHg
HR : 80 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (+)
Laboratory Findings : 19/02/2020
- Blood Glucose 165 mg/dL (06.00)
- Blood Glucose 143 mg/dL (11.00)
- Blood Glucose 257 (17.00)
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy

Thursday, February 20 2020

S Nausea and vomit less than yesterday. No more weakness. History of type 2
diabetes mellitus and heart disease.
O Vital Sign
BP : 120/80 mmHg
HR : 75 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (+)
Laboratory Findings : 20/02/2020
- Blood Glucose 222 mg/dL (11.00)
- Blood Glucose 180 mg/dL (17.00)
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
 Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy

Thursday, February 21 2020

S Nausea and vomit (-). No more weakness. History of type 2 diabetes mellitus
and heart disease.
O Vital Sign
BP : 120/80 mmHg
HR : 88 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (-)
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy
 CHAPTER II
LITERATUR REVIEW

A. DIABETES MELLITUS
Population health is defined as “the health outcomes of a group of
individuals, including the distribution of health out comes within the group”; these
out comes can be measured in terms of health out comes (mortality, morbidity,
health, and functional status), disease burden (incidence and prevalence), and
behavioral and metabolic factors (exercise, diet, A1C, etc.)

1. CLASSIFICATION.

Diabetes can be classified into the following general categories:

- Type 1 diabetes (due to autoimmune b-cell destruction, usually leading to

absolute insulin deficiency)

- Type 2 diabetes (due to aprogressive loss of b-cell insulin secretion

frequently on the background of insulin resistance)

- Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second

or third trimester of pregnancy that was not clearly overt diabetes prior to
gestation)

- Specific types of diabetes due to other causes, e.g., monogenic diabetes

syndromes (such as neonatal diabetes and maturity-onset diabetes of the
young [MODY]), diseases of the exocrine pancreas (such as cystic
fibrosis and pancreatitis), and drug or chemical-induced diabetes (such as
with glucocorticoid use, in the treatment of HIV/AIDS, or after organ
transplantation)
 Type 1 diabetes and type 2 diabetes are heterogeneous diseases in which
clinical presentation and disease progression may vary considerably.
Classification is important for determining therapy, but some individuals
cannot be clearly classified as having type 1 or type 2 diabetes at the time of
diagnosis. The traditional paradigms of type 2 diabetes occurring only in
adults and type 1 diabetes only in children are no longer accurate, as both
diseases occur in both age-groups.
In both type 1 and type 2 diabetes, various genetic and environmental
factors can result in the progressive loss of b-cell mass and/or function that
manifests clinically as hyperglycemia. Once hyperglycemia occurs, patients
with all forms of diabetes are at risk for developing the same chronic
complications, although rates of progression may differ.

2. DIAGNOSTIC TESTS.

Diabetes may be diagnosed based on plasma glucose criteria, either the

fasting plasma glucose (FPG) value or the 2-h plasma glucose (2-h PG) value
during a 75-g oral glucose tolerance test (OGTT), or A1C criteria (6) (Table
2.2). Generally, FPG, 2-h PG during 75-g OGTT, and A1C are equally
appropriate for diagnostic testing. It should be noted that the tests do not
necessarily detect diabetes in the same individuals. The efficacy of
interventions for primary prevention of type 2 diabetes has primarily been
demonstrated among individuals who have impaired glucose tolerance (IGT)
with or without elevated fasting glucose, not for individuals with isolated
impaired fasting glucose (IFG) or for those with prediabetes defined by A1C
criteria.

Fasting and 2-Hour Plasma. Glucose The FPG and 2-h PG may be used
to diagnose diabetes (Table 2.2). The concordance between the FPG and 2-h
PG tests is imperfect, as is the concordance between A1C and either glucose-
 based test. Compared with FPG and A1C cut points, the 2-h PG value
diagnoses more people with prediabetes and diabetes.

AIC. The A1C test should be performed using a method that is certified
by the NGSP (www.ngsp.org) and standardized or traceable to the Diabetes
Control and Complications Trial (DCCT) reference assay. When using A1C to
diagnose diabetes, it is important to recognize that A1C is an indirect measure
of average blood glucose levels and to take other factors into consideration
that may impact hemoglobin glycation independently of glycemia including
HIV treatment, age, race / ethnicity, pregnancy status, genetic background,
and anemia / hemoglobinopathies.

Criteria for the diagnosis of diabetes :

1. FPG >126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for
at least 8 h.

2. 2-h PG $200 mg/dL (11.1 mmol/L) during OGTT. The test should be
performed as described by the WHO, using a glucose load containing the
equivalent of 75-g anhydrous glucose dissolved in water.*.

3. A1C $6.5% (48 mmol/mol). The test should be performed in a laboratory

using a method that is NGSP certified and standardized to the DCCT
assay.*

4. In a patient with classic symptoms of hyperglycemia or hyperglycemic

crisis, a random plasma glucose $200 mg/dL (11.1 mmol/L).

3. RISK FACTORS.

“Prediabetes” is the term used for individuals whose glucose levels do

not meet the criteria for diabetes but are too high to be considered normal.
(Patients with prediabetes are defined by the presence of IFG and/or IGT
and/or A1C 5.7–6.4% (39–47 mmol/mol). Prediabetes should not be viewed
as a clinical entity in its own right but rather as an increased risk for diabetes
and cardiovascular disease (CVD). Criteria for testing for diabetes or
prediabetes in asymptomatic adults. Prediabetes is associated with obesity
(especially abdominal or visceralobesity), dyslipidemia with high
triglycerides and/or low HDL cholesterol, and hypertension.

Criteria for testing for diabetes or prediabetes in asymptomatic adults

1. Testing should be considered in overweight or obese (BMI >25 kg/m2 or
>23 kg/m2 in Asian Americans) adults who have one or more of the
following risk factors:
a. c First-degree relative with diabetes
b. c High-risk race/ethnicity (e.g., African American, Latino, Native
American, Asian American, Pacific Islander)
c. History of CVD
d. Hypertension ($140/90 mmHg or on therapy for hypertension)
e. HDL cholesterol level ,35 mg/dL (0.90 mmol/L) and/or a
triglyceride level .250 mg/dL (2.82 mmol/L)
f. Women with polycystic ovary syndrome
g. Physical inactivity
h. Other clinical conditions associated with insulin resistance (e.g.,
severe obesity, acanthosis nigricans)
2. Patients with prediabetes (A1C $5.7% [39 mmol/mol], IGT, or IFG)
should be tested yearly.
3. Women who were diagnosed with GDM should have lifelong testing at
least every 3 years.
4. For all other patients, testing should begin at age 45 years.
5. If results are normal, testing should be repeated at a minimum of 3-year
intervals, with consideration of more frequent testing depending on initial
results and risk status.
4. PREVENTION

Physical Activity. Just as 150 min/week of moderateintensity physical

activity, such as brisk walking, showed beneficial effects in those with
prediabetes (1), moderateintensity physical activity has been shown to
improve insulin sensitivity and reduce abdominal fat in children and young
adults.

Nutrition. Structured behavioral weight loss therapy, including a reduced

calorie meal plan and physical activity, is of paramount importance for those
at high riskfordevelopingtype2diabeteswho have overweight or obesity.

Tobacco Use. Smoking may increase the risk of type 2 diabetes

therefore, evaluation for tobacco use and referral for tobacco cessation, if
indicated, should be part of routine care for those at risk for diabetes. Of note,
the years immediately following smoking cessation may represent a time of
increased risk for diabetes.

5. TREATMENT.
Assessment of hypoglycemia risk
Factors that increase risk of treatment-associated hypoglycemia
- Use of insulin or insulin secretagogues (i.e., sulfonylureas,
meglitinides)
- Impaired kidney or hepatic function
- Longer duration of diabetes
- Frailty and older age
- Cognitive impairment
- Impaired counterregulatory response, hypoglycemia unawareness
- Physical or intellectual disability that may impair behavioral
response to hypoglycemia
- Alcohol use
- Polypharmacy (especially ACE inhibitors, angiotensin receptor
blockers, nonselective b-blockers).
B. DYSPEPSIA
Dyspepsia is any symptom of the upper gastrointestinal tract (GI),
present for 4 weeks or more, including upper abdominal pain or discomfort,
heartburn, acid reflux, nausea, or vomiting. The guideline applies to adults
(aged 18 and over) with symptoms suggestive of dyspepsia, symptoms
suggestive of gastro-oesophageal reflux disease (GORD), or both.
1. CLINICAL SYMPTOMS

- Epigastric pain

- Epigastric fullness

- Nausea

- Vomiting

- Heartburn

2. DIAGNOSTIC TEST.

- Test for H pylori using a carbon-13 urea breath test or a stool antigen
test, or laboratory-based serology where its performance has been locally
validated.

- Do not use office-based serological tests for H pylori because of their

inadequate performance.

3. TREATMENT.

- Offer people who test positive for H pylori a 7-day, twice-daily course of
treatment with:

a. PPI

b. amoxicillin and

c. either clarithromycin or metronidazole

- Offer people who are allergic to penicillin4 a 7-day, twice-daily course of

treatment with:

a. PPI (see table 3 in the overview section)

b. clarithromycin and
 c. metronidazole

Treatment non farmacology

- Review lifestyle factors (eg, diet, weight, smoking, alcohol).

- If alarm signals indicate organic disease, refer to specialist for OGD.

- If there is heartburn and dyspepsia, treat as GORD in the first instance.

- Review person’s intake of all medications, especially NSAIDs.

- Commence empiric therapy in those without alarm signals or heartburn.

- If there is concurrent use of NSAIDs, evaluate for risk of GI

complications, and consider alternative strategies if risk is increased. (See
Chapter 5: NSAIDs and GI Complications.)
 REFERENCE

National Institute for Health and Care Excellence. 2014. Dyspepsia and
gastrooesophageal reflux disease: investigation and management of dyspepsia,
symptoms suggestive of gastro-oesophageal reflux disease, or both Clinical
guideline (update).
New Zealand Guidelines Group. 2004. Management of Dyspepsia Heartburn.
American Diabetes Association. 2019. Standards of Medical Care In Diabetes.
Perkeni. 2015. Pengelolaan dan Pencegahan Diabetes Mellitus Tipe 2 Di Indonesia.