MORNING REPORT

Monday, November 25th 2013 STUDENT INCHARGE: Coass in charge : Adma Febri Achmad Arrizal Supervisor : dr. Sri Sunarti, Sp.PD

Summary of Data Base

Mr. Utomo / 33 yo
Chief complain: Legs and upper arm cant be 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 worsened since yesterday night (November 23rd 2013), his legs couldnt be moved. He couldnt move so that he came to ER. He felt he couldnt move from his legs until his back. Fever (-), cough (-), cold (-), nausea (-), vomiting (-). He felt 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.

 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

SUMMARY OF DATA BASE

History of social living : he is married, has one 4-yearchildren. 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.

Physical examination
BP: 110/70 mmHg PR: 66 bpm regular strong RR: 18 tpm Tax: 36.5C General appearance looked moderately ill Head Pale conjunctiva Icterus Sclera JVP R + 0 cmH2O 30 degree, lymphnode enlargement Heart: Ictus invisible and palpable at ICS V MCL Sinistra LHM ictus RHM: SL D S1, S2 single, murmur Symetric, SF D= S s s s s s s Rh - --Wh - --GCS: 456

Neck Chest

Lung:

Abdomen Extremities

Flat, soefl, liver span 8 cm, traube space tympani, bowel sound (+) normal Sensoric: normal, edema (-), warm acral motoric 5 5 4 | 4 5 5 432|234

Laboratory findings
LAB
Hb

VALUE
17.00

(NORMAL)
11,0-16,5 g/dL

LAB
RBS

VALUE
123

(NORMAL)
< 200 mg/dl

MCV
MCH Leucocyte

77.10
28.20 12,950

80-96 fl
26,5-33,5 pg 3.500-10.000/L

Ureum
Creatinine SGOT SGPT

20.60
0.86 27 8

10-50 mg/dL
0,7-1,5 mg/dL 11-41U/L 10-41U/L

Eos / Bas / Neu / Limf / Mon

0.5/ 0.1/ 79.2 / 13.7 /6.3 %

Ht Plt Natrium Kalium Chlorida 46.40 329.000 138 2.05 108 38-42% 150.000-390.000/L 136-145 mmol/L 3,5-5,0 mmol/L 98-106 mmol/L

T3
T4 TSH

0.83
1.10 1.33

0.8-2 mg/dL
0.93-1.7 mg/dL 0.270-4.2 mg/dL

Blood Gas Analysis

Lab pH pCO2 7.45 31.9 mmHg Value 7.35 7.45 35 - 45

pO2
HCO3 Base Excess O2 Saturation Conclussion:

87.2 mmHg
22.5 mmol/L -1.7 mmol/L 97.0% Normal limit

80 - 100
21 - 28 (-3) (+3) > 95%

URINALISIS
Result Color, Turbidity SG PH Yellow, Clear 1,010 6,5 10 x Result

Epithelia
Cylinder Hyaline Granular 40 x

+ Negative

Leucocyte
Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin

Negative
Negative Negative Negative Negative Negative Negative

Eritrosit
Leukocyte

0.1 3.6 -

Chrystal
Bacteria

Negative

CUE AND CLUE

PL

IDx

PDx

PTx Bed rest Diet 1500 ccal/day IVFD NaCl 0.9% 20 dpm Drip KCl 20 mEq/hours If K post correction > 2.5 mmol/L drip stop, change to PO KSR 3x1 tab and fruit diet especially green banana Consult to Neurologic Department

Pmo S, V S, SE 4h post correctio n, Muscle strength, ROM

PED Conditio n, Green banana consum ption

Male/33yo/25 1. Tetraparese 1.1 dt(March, 13th -2013) CXR A: Hipokalemia Paralysis 3 days 1.2 dt GBS History of paralysis 6 AP months agoposition, symmetric, enough KV, less inspiration Trachea History of GBS 6 : in the middle months ago tissue and bone : normal Soft Right & left phrenico-costalis angle : sharp PE: Right & Left hemidiaphragm : dome-shaped BP: 110/70 mmHg strong, Lung :reguler BV pattern normal PR: 66 Cor : Site normal, Shape: Normal, CTR : 48% RR: 18x/min Tax: 36.5 Extremity: Conclusion: Normal Sensoric: normal Motorik: 5-5-4 | 4-5-5 4-3-2 | 2-3-4 LAB: K: 2.05 mmol/L

CUE AND CLUE 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

PL 2. Hipokalemia

IDx 2.1 dt Hiperaldoste ronemia primer 1.2 dt

PDx Aldos teron level Kaliu m urine

PTx Bed rest Diet 1500 ccal/day IVFD NaCl 0.9% 20 dpm Drip KCl 20 mEq/hours If K post correction > 2.5 mmol/L drip stop, change to PO KSR 3x1 tab and fruit diet especially green banana Consult to Neurologic Department

Pmo S, V S, SE 4h post correctio n, Muscle strength, ROM

PED Conditio n, Green banana consum ption

Condition this morning

Thank you