Professional Documents
Culture Documents
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
:
Additional Complaint
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.
PHYSICAL EXAMINATION
Vital Sign
PHYSICAL EXAMINATION
General Status
Head
Eyes
Neck
Thorax
I
P
P
A
: Normocephal
: Anemic conjungtiva (-), Icteric sclera (-)
: Lymph nodes (-), JVP 5-2 cmH2O
:
:
:
:
Cor
I
P
P
A
:
:
:
:
:
:
:
:
Abdomen
I
A
P
P
Extremities
Types of examination
Results
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