Summary of Data Base

Mrs N/48yo
Chief Complaint : General weakness
Patient suffered from general weakness since a week before
admission. She told that this complaint had bothering
her and she couldnt do her daily routine properely. She
had been taking medicine prescribed from puskesmas
sungai raya and some herbal medicine from her
neighbour but her complaint was not getting better,
even worse for these past 3 days.
Patient also suffered from tingling and numness sensation
on her fingers since 3 days before admission. She told
that this complaint was never getting better but she
didnt take any medicine for this complaint specifivally

Past medical history

She had been diagnosed with
diabetes mellitus from puskesmas
sungai raya since 3 months ago and
she took metformin twice a day since
then, but she told that her glucose
level was staying in 200 mg/dl or so
and her complaint was never getting
better
She was also diagnosed with long
standing hypertension since 3 years

Physical examination
BP 140/70 mmHg

PR = 97 bpm

General appearance looked severely ill

Head

Pale conjunctiva -

Neck

JVP R + 2 cmH2O

Chest

RR = 20 tpm

Tax : 36.7 C

GCS 456 BMI

Heart:

Ictus invisible and palpable at 2 cm lat MCL ICS V Sinistra

LHM ictus, heart waist +
RHM: SL Dextra
S1, S2 single with no murmur

Lung:

Symetric,

s s vv
s s vv
s s vv

Rh - ---

Wh - ---

Abdomen
External Genetalia

liver span 10cm,troube space tympani, bowel sound (+) normal

Catheter urine 50cc/hour

Extremities

Edema (-), CRT<2 seconds

Lab

Value

Leukocyte

8500

3.500-10.000/L

Haemoglobine

9.8

11,0-16,5 g/dl

HCT

32.4

35-50%

Trombocyte

185.00
0

150.000390.000/L

MCV
MCH

81
27

Ureum

39

15-45Mg/dl

Creatinin

1.5

0.6-1.1 mg/dl

Lab

Value

RBG

241
mg/dl

ECG
Sinus rhythm, heart rate 100 bpm
Frontal Axis
: normal
Horizontal Axis
: Counter clockwise
PR interval
:0.16
QRS complex : 0.04
QT interval
: 0.32

Conclusion : sinus rhythm HR 100 bpm

CXR

AP position, asymmetric, too strong KV, less Inspiration

Trachea in the middle
Soft tissue and bone normal
Hemidiaphragma D/S domeshape,
Sinus prenicocostalis angle D/S sharp
Pulmo : looks infiltrate pulmo D/S
Cor : CTR 63%, heart waist -, aorta elongation

Conclusion: cardiomegaly, aortic elongation

CUE AND
CLUE

PROBLEM
LIST

female/ 48
yo
General
weakness

1. Type 2
DM
poorly
contro
lled

History DM
since 3
months ago
Consumed
metformin
twice a day
since
diagnosed

INITIAL
DIAGNOSE

PLANNIN
G
DIAGNOS
E

PLANNING THERAPY

PLANNI
NG
MONITO
RING

Diet: Low calori,

Low Fat,
Exercise
Metrformin
3x500mg
Basal Insulin 10
U sc

FBS
2HPP

CUE AND
CLUE

PROBLEM LIST

female/ 48
yo
Numbness
and pain both
of foot
And fingers

2.
Neuropath
y diabetic

INITIA
L
DIAGN
OSE

PLANNIN
G
DIAGNOS
E

PLANNING THERAPY

Gabapentin
1x100mg
Mecobalamin
1x1 p.o

PLANNI
NG
MONIT
ORING

CUE AND
CLUE

PROBLEM
LIST

INITIAL
DIAGNOS
E

PLANNIN
G
DIAGNOS
E

female/ 48
yo
History of
uncontrolled
HT

3. HT st I

3.1
Primary
HT
3.2
second
CUE
ary
HTAND CLUE

PLANNING THERAPY

Valsartan 1x
80mg

PLANNI
NG
MONIT
ORING

Thank you