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MORNING REPORTMonday, November 25th2013
STUDENT INCHARGE:Coass in charge :
Adma Febri
Achmad Arrizal
Supervisor : dr. Sri Sunarti, Sp.PD
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Summary of Data BaseMr. Utomo / 33 yo
Chief complain: Legs and upper arm cantbe moved
Patient couldnt move his legs and upper arm since 6
months ago, it was intermittently. Last two days, they were
paralized, especially his thighs. Paralysis has been worsenedsince yesterday night (November 23rd 2013), his legs
couldnt be moved. He couldnt move so that he came to
ER. He felt he couldntmove from his legs until his back.
Fever (-), cough (-), cold (-), nausea (-), vomiting (-). Hefelt the increasing body weight, his appetite was not
changed (3-4 times a day), every day he eats vegetables and
fruits. His defecation and urination is in normal limit.
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Past medical history: he patient was suffered
from Guillain Barre Syndrome at RSSA 6
months ago with the same complaints. He was
hospitalized for a week, but he forced to go
home. After that, he never controlled and
took a medication. He went to midwive and
was given injection. Family history: no family has the same
complaints
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SUMMARY OF DATA BASE
History of social living : he is married, has one 4-year-children. He is mechanic. He is smoking since
elementary school, 1-2 packs a day. He drank alcohol
since 17 years old but stopped since 7 years ago. He
has chicken poultry.
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Physical examinationBP: 110/70 mmHg PR: 66 bpm regular
strong
RR: 18 tpm Tax: 36.5C
General appearance looked moderately ill GCS: 456
Head Pale conjunctiva -
Icterus Sclera -
Neck JVP R + 0 cmH2O 30 degree, lymphnode enlargement -
Chest Heart: Ictus invisible and palpable at ICS V MCL Sinistra
LHM ictus
RHM: SL D
S1, S2 single, murmur -
Lung: Symetric, SF D= S s s Rh - - Wh - -
s s - - - -s s - - - -
Abdomen Flat, soefl, liver span 8 cm, traube space tympani, bowel sound (+) normal
Extremities Sensoric: normal, edema (-), warm acral
motoric 554 | 455
432 | 234
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Laboratory findingsLAB VALUE (NORMAL) LAB VALUE (NORMAL)
Hb 17.00 11,0-16,5 g/dL RBS 123 < 200 mg/dlMCV 77.10 80-96 fl Ureum 20.60 10-50 mg/dL
MCH 28.20 26,5-33,5 pg Creatinine 0.86 0,7-1,5 mg/dL
Leucocyte 12,950 3.500-10.000/L SGOT 27 11-41U/L
Eos / Bas / Neu / Limf / Mon SGPT 8 10-41U/L
0.5/ 0.1/ 79.2/ 13.7/6.3 % T3 0.83 0.8-2 mg/dL
Ht 46.40 38-42% T4 1.10 0.93-1.7 mg/dL
Plt 329.000 150.000-390.000/L TSH 1.33 0.270-4.2 mg/dL
Natrium 138 136-145 mmol/L
Kalium 2.05 3,5-5,0 mmol/L
Chlorida 108 98-106 mmol/L
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Blood Gas Analysis
Lab Value
pH 7.45 7.357.45
pCO2 31.9 mmHg 35 - 45
pO2 87.2 mmHg 80 - 100
HCO3 22.5 mmol/L 21 - 28
Base Excess -1.7 mmol/L (-3)(+3)
O2Saturation 97.0% > 95%
Conclussion: Normal limit
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URINALISIS
Result Result
Color, Turbidity Yellow, Clear10 x
SG 1,010Epithelia +
PH 6,5Cylinder Negative
Leucocyte NegativeHyaline -
Nitrite NegativeGranular
-
Protein Negative 40 x
Glucose Negative Eritrosit 0.1
Erythrocyte NegativeLeukocyte 3.6
Keton urine Negative Chrystal -
Urobilinogen Negative Bacteria -
Bilirubin Negative
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CXR (March, 13th 2013)
AP position, symmetric, enough KV, less inspiration
Trachea : in the middle
Soft tissue and bone : normal
Right & left phrenico-costalis angle : sharp
Right & Left hemidiaphragm : dome-shaped
Lung : BV pattern normal Cor : Site normal, Shape: Normal, CTR : 48%
Conclusion: Normal
CUE AND CLUE PL IDx PDx PTx Pmo PED
Male/33yo/25
A:
Paralysis 3 days
History of paralysis 6
months ago
History of GBS 6
months ago
PE:
BP: 110/70 mmHg
PR: 66 strong, regulerRR: 18x/min
Tax: 36.5
Extremity:
Sensoric: normal
Motorik:
5-5-4 | 4-5-5
4-3-2 | 2-3-4
LAB:
K: 2.05 mmol/L
1. Tetraparese 1.1 dt
Hipokalemia
1.2 dt GBS
- Bed rest
Diet 1500
ccal/day
IVFD NaCl 0.9%
20 dpm
Drip KCl 20
mEq/hours
If K post
correction > 2.5
mmol/Ldrip
stop, change toPO KSR 3x1 tab
and fruit diet
especially green
banana
Consult to
Neurologic
Department
S, V S, SE
4h post
correctio
n,
Muscle
strength,
ROM
Conditio
n, Green
banana
consum
ption
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CUE AND CLUE PL IDx PDx PTx Pmo PED
Male/33yo/25
A:
Paralysis 3 days
History of paralysis
6 months ago
History of GBS 6
months ago
PE:
BP: 110/70 mmHg
PR: 66 strong,reguler
RR: 18x/min
Tax: 36.5
Extremity:
Sensoric: normal
Motorik:
5-5-4 | 4-5-5
4-3-2 | 2-3-4
LAB:
K: 2.05 mmol/L
2. Hipokalemia 2.1 dt
Hiperaldoste
ronemia
primer
1.2 dt
Aldos
teron
level
Kaliu
m
urine
Bed rest
Diet 1500
ccal/day
IVFD NaCl 0.9%
20 dpm
Drip KCl 20
mEq/hours
If K post
correction > 2.5
mmol/Ldrip
stop, change toPO KSR 3x1 tab
and fruit diet
especially green
banana
Consult to
Neurologic
Department
S, V S, SE
4h post
correctio
n,
Muscle
strength,
ROM
Conditio
n, Green
banana
consum
ption
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Condition this morning
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Thank you
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