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NIGHT DUTY REPORT

Wednesday, 1st October


2015
Coass on Duty :
Sheira
Anry

Recapitulation Patients

PATIENTS IDENTITY
Name
: Mrs. D
Age
: 34 years old
Marital status : Married
Occupation : teacher
Religion
: Moeslem
Adress
: Menteng, Jakarta Pusat

ANAMNESIS
Anamnesis
Chief Complaint

: Auto-anamnesis
:

Weakness on both lower extremities since 1 week before


admission

Additional Complaint

Tingling on all over her body

CURRENT ILLNESS
Patient came with a complaint of weakness on both
lower extremities since 1 week before admission.
Patient said the weakness is getting worse day by day,
and it goes on all day long. First, patient felt weakness
on thight of both legs and slowly radiating to the soles
of the two feet. 2 months ago patient experience same
symptoms and diagnose as electrolyte imbalance.
Patient also felt tingling all over her body. No history of
trauma or exercise. Nausea (-), vomit (-), sweating (-),
palpitation (-), dyspnea (-), dizzy (-), headache (-), fever
(-), normal micturition and defecation.

PAST ILLNESS HISTORY


Hypertension since 2009
Adrenal adenoma since 2011 (surgery will be performed
after Potassium correction)
Diabetes Mellitus (-)
Heart disease (-)
Kidney disease (-)

FAMILY ILLNESS HISTORY : HABIT STATUS


:-

PHYSICAL EXAMINATION
Vital Sign

General condition : moderately ill


Consciousness
: Compos Mentis
BP
: 130/90 mmHg
HR
: 75 x/min
RR
: 20 x/min
Temp.
: 36 C

PHYSICAL EXAMINATION
General Status

Head
Eyes
Neck
Thorax

I
P
P
A

: Normocephal
: Anemic conjungtiva (-), Icteric sclera (-)
: Lymph nodes (-), JVP 5-2 cmH2O
:
:
:
:

Symmetric when static or dynamic


Vocal Fremitus (N)
Sonor on both lungs parts
Vesicular, Wh -/- , Rh -/-

Cor

I
P
P
A

:
:
:
:

Ictus Cordis (-)


Ictus Cordis (+) on ICS V linea mid clavicular sinistra
normal heart border
normal heart sounds (I & II), murmur (-), gallop (-)

:
:
:
:

Ascites (-), normal skin color


normal bowel sound
Tympanic sound on all abdomen parts
Epigastric tenderness (-), hepatomegaly (-)

Abdomen

I
A
P
P

Extremities

: CRT <2 seconds, edema (-), motoric inferior 2222/2222

Types of examination

Results

Normal range values

Hb

9.8

12-16 g/dl

Ht

31

37-47%

Erythrocyte

4.1

4.3-6.0 million/uL

Leucocyte

3900

4.800-10.800/uL

Platelet

319000

150.000-400.000/uL

MCV

75

80-96 fL

MCH

24

27-32 pg

MCHC

32

32-36 g/dL

SGOT

75

<35 U/L

SGPT

34

<40 U/L

Ureum

18

20-50 mg/dL

Creatinin

0.6

0,5-1,5 mg/dL

Calcium

9.2

8.6-10.3 mg/dl

Magnesium

1.80

1.8-3.0 mEq/L

Chloride

93

<140mg/d;L

Natrium

146

135-147 mmol/L

Kalium

1.5

3.5-5.0 mmol/L

RESUME
A female patient, 34 years old with complaint weakness
on both lower extremities since 1 week before
admission. The weakness is getting worse day by day.
The patient also felt tingling on all over her body.
Patient experienced symptoms like this 2 months ago
and diagnose with electrolyte imbalance. Patient had
history of adrenal adenoma since 2011.
On physical examination, vital signs are normal, motoric
inferior 2222/2222

PROBLEMS LIST
Hypertension
From her past illness history

Hypokalemia
Lower extremities weakness
Potassium = 1,5 on laboratory examination

Adrenal adenoma
From her past illness history (Anamnesis)

PLANNING
Hypertension
Spironolactone 50mg once daily
Hypokalemia
Laboratory test: Blood Glucose, Blood Gas Analysis,
Electrolytes Corection post 24 hours
IVFD RL 2500 ml/24 hours + KCl 25 Meq
Adrenal Adenoma
Surgical procedure after potassium correction by
internal medicine department (expert consultation to
surgical department)

THANK YOU