Summary of Database

Mrs. R/41 yo/ward 13

Autoanamnese

Chief Complaint:
Tingling sensation

History of Present Illness:

Patient felt tingling sensation at her left and right foot since a year ago. She has been
diagnosed with Nasopharyngeal carcinoma since a year and had undergone chemotherapy at
third cycle of 5 in fifth series. She never had diabetes mellitus history, her blood glucose at
three weeks ago was normal. Her bodyweight decreases 15 kgs since the first chemotherapy.
 Summary of Database
Past Medical History:
-

Family History:
her mother had tumour at her back, it was said to be lipoma

Social History:
she is a housewife with 2 daughters

Review of System:
fever (-), nausea (+), vomiting (-), weakness (-)
 Physical Examination
General appearance look mildly ill Sat O2 % on lpm
GCS 456 CM VAS 0/10
BP 110/70 mmHg PR 72 bpm regular strong RR 20 tpm Tax 36,4oC
Head Conjuctiva Anemic (-), Sclera Icteric (-)
Neck JVP R+ cmH20, nodul regio colli dextra, 1x1x1 cm, mobile (+), tenderness (-)
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi: -| - Wheezing : -| -
Sonor | Sonor Vesicular | Vesicular -|- -|-
Sonor | Sonor Vesicular | Vesicular -|- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 9 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany
Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization(-)
5|5
 Laboratory Findings (9/7/19)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 2.860 4.700 – 11.300 /µL Ureum 16 20-40 mg/dL

Hemoglobine 12,8 11,4 - 15,1 g/dl Creatinine 0,54 <1,2 mg/dL

PCV 36,3% 38 - 42%

Thrombocyte 201.000 142.000 – 424.000 /µL Natrium 135 136-145 mmol/L

MCV - 80-93 fl Kalium 3,42 3,5-5,0 mmol/L

MCH - 27-31 pg Chlorida 101 98-106 mmol/L

Eo/Bas/Neu/ 2,4/0,3/25/54, 0-4/0-1/51-67/ RBS 263 < 200 mg/dl

Limf/Mon 5/17,8 25-33/2-5
PPT - 9.3-11.4 seconds
SGOT 51 0-40 U/L APTT - 24.8-34.4

SGPT 74 0-41 U/L INR - 0.8-1.30

Albumin 4,73 3.5-5.5 g/dL Calcium - 7,6-11,0

Bilirubin total - <1.0 mg/dl

Bilirubin direct - <0.25 mg/dl Osm - 275-295 mOsm/kg

Bilirubin indirect - <0.75 mg/dl

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. R/41 yo/ward 13 1. 1.1 Reactive - HbA1c - IVFD NaCl 0,9% FPG/2hPPG
Hyperglycemic 1.2 DM type 2 - FPG, rehydration, continue with
Subjective state 2hPPG 1500 cc/24 hrs
history of DM (-) maintenance
- OAD wait for lab result
Objective
GCS 456

Laboratory (9/7/19)
RBS : 400 mg/dL
RBS at 19.46 : 263 mg/dL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. R/41 yo/ward 13 2. Chemotherapy C5FU as - side effect
Nasopharynge indicated by ENT of
Subjective al carcinoma Department chemother
mass at her neck (+) stadium 2 on apy
difficulty to swallow (-) chemotherapy
C5FU
Objective
Neck: nodul regio colli D,
1x1x1 cm, soft, mobile,
tenderness (-)

Biopsi Colli S
Metastasis undifferentiated
carcinona
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. R/41 yo/ward 13 3. Neutropenia 3.1 - treat as ENT department CBC
Chemotherapy protocol
Subjective induced - SC GCSF 1x300 mcg until
- ANC > 1500

Objective
GCS 456

Laboratory (9/7/19)
Diff (%) :
2.4/0.3/25.0/54.5/17.8
ANC : 710 /uL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. R/41 yo/ward 13 4. Neuropathy 4.1 Side effect - HbA1c - OAD wait for lab result FPG/2hPPG
of - FPG, - PO Gabapentin 1x300 mg
Subjective chemotherapy 2hPPG
tingling at feet (+) 4.2 Diabetic
history of DM (-) neuropathy

Objective
sensoric sensation << feet
Problem Analysis
 Risk Factors Analysis
Problem Theory Patient
Key Message Pathophysiology
Key Message Diagnosis
 Management Analysis

Problem Theory Patient

Key Message Management
Key Message Social
Condition This Morning
 Prognosis

• Ad vitam :
• Ad functionam :
• Ad sanationam :