Morning Report

April 17 2015
th

Coass in charge :
Cristian Rajagukguk
Rudi Rakhmad H
Supervisor :
dr. Laksmi S, SpPD-KEMD

SUMMARY OF DATA BASE

Mr Kariono/48 yo/W.26

History Taking : Heteroanamnesis from his wife

Chief complain : nausea and vomiting
Patient suffered from nausea and vomiting since 9 hours before admission after
he was exposed by pesticida. He drank that pesticide, after that he vomited >5x,
contained fluid about 50cc/each. He also complained about pain in his eyes,his
eyes wattery because of pesticide. His passing stool and passing urine whitin
normal limit.
He was admitted at PHC and got sulphas atrophine 3x0.25 mg intravena and ranitidine 1x50
mg intravena. He was referred to RSSA for further treatment
Family history : Pass medical history: -

Physical Examination
BP = 110/70 mmHg

PR = 63 bpm

RR = 20 tpm

General appearance looked moderately ill

Head

Pupil midriasis isokor

8mm/8mm, lacrimation (+)
Pupil reflex +/+
Pale conjunctiva Icterus Sclera -

Neck
Chest

GCS 456

Tax : 36.7C

Looked normoweight

Inserted NGT

JVP R + 1 cmH2O 30 degree, lymphnode enlargement Heart:

Ictus visible and palpable at ICS V at MCL Sinistra

LHM ~ ictus
RHM ~ PSL D
S1, S2 single, murmur (-)

Lung:

Symetric, Rh - ---

Wh - ---

V V
V V
V V

S S
S S
S S

Abdomen

Flat, soefl, bowel sound (+) N, traube space thympany, liver span 9 cm

Extremities

Warm acral
Edema (-)
UOP 20cc/hour

LABORATORY FINDINGS
Lab
Leuco
Diff count
Hb

Value

Lab

Value

17300

4000-11.000/L

Ur

21.5

16,6-48,5 mg/dL

0.2/0.2/84/
12.9/2.7

0-4/0-1/5167/25-33/2-5 %

Cr

0.77

< 1,2 mg/dL

11-16,5 g/dL

RBS

98

<200 mg/dL

13.6

MCV

76.70

80-93 fl

Na

138

136-145mmol/l

MCH

26.70

27-31pg

3.85

3,5-5,0 mmol/l

PCV

39.1

40-47 %

Cl

111

98-106 mmol/l

Thromboc
yte

235000

150-450x103/L

SGOT

20

11-41U/L

SGPT

19

11-41U/L

URINALYSIS
Lab

Value

Urinalysis

Lab
10 x

Value

SG

>1.030

Epithelia

3.2

PH

5.5

Cylinder

Leucocyte

Hyaline

Nitrite

Granular

Protein

Trace

Leukocyte

Glucose

Erythrocyte

Erythrocyte

40 x
Erythrocyte

4.0

Keton urine

Leukocyte

Urobilinogen

Crystal

Bilirubin

Bacteria

58.7

BLOOD GAS ANALYSIS

pH

7,31

7,35-7,45

pCO2

38.1

35-45

mmHg

pO2

27.6

80-100

mmHg

HCO3
BE

19.2
-7.4

21-45
(-3) ( +3)

mmol/L
mmol/L

O2 saturation

48.9

>95

Hb

13.3

Temperature

37.0

BGA conclusion Vena sampling

g/dL

ECG

ECG
Sinus rhythm with heart rate 64 bpm
Frontal Axis

: Normal

Horizontal Axis

: Normal

PR interval

: 0.12

QRS complex

: 0.08

QT interval

: 0.36

Tall T V2-V5
Conclusion : sinus rhythm with heart rate 64 bpm +
Tall T

CXR

CXR
AP position, asymmetric, enough KV, enough
inspiration
Soft tissue normal, Bone normal
Trachea is in the middle
Hemi diaphragm D and S were dome shape
Phrenico costalis angle D/S were sharp
Pulmo D & S: BVP normal
Cor: site N, CTR 49%, cardiac waist (+)
Conclusion : Normal CXR

CUE AND CLUE

PL

Male/ 48 yo/ w26

Anamnesis:
Nausea and vomiting
Lacrimation
Pain in his eyes
Exposed by pesticide
History got Sulphas atrophin
at PHC
Physical examination:
GCS 456
BP: 110/70 mmHg
PR: 63 bpm
RR: 20 tpm
Tax: 36.7 degree celcius
Lacrimation, pupil miosis
pupil midriasis 8mm/8mm

1.
Orghanophosph
ate intoxication

Laboratory:
ECG :
sinus rhythm with heart rate
64 bpm

Idx

PDx
Toxicology

PTx
O2 10 lpm NRBM
Fasting
Insert NGT
Insert catether urination
Inj sulphas atrophine 1 mg/6 hours
until the PR>100x/minutes
Inj lansoprazole 1x30 mg iv
IVFD NS:D5% = 2:1 + 20 dpm

Pmo
Monitoring:
S, VS

Education
Disease, treatment, prognosis

CUE AND CLUE

PL

Male/ 48 yo/ w26

Anamnesis:
Nausea and vomiting
Lacrimation
Pain in his eyes
Exposed by pesticide
History got Sulphas atrophin
at PHC
Physical examination:
GCS 456
BP: 110/70 mmHg
PR: 63 bpm
RR: 20 tpm
Tax: 36.7 degree celcius
Lacrimation, pupil miosis
pupil midriasis 8mm/8mm

2. Leucocytosis

Laboratory:
Leucocyte 17300

Idx
2.1 dt no 1

PDx

PTx
Inj ceftriaxone 2x1 g iv

Pmo
Monitoring:
S, VS
DL

Education
Disease, treatment, prognosis

CUE AND CLUE

Male/ 48 yo/ w26
Anamnesis:
Nausea and vomiting
Lacrimation
Pain in his eyes
Exposed by pesticide
History got Sulphas atrophin
at PHC
Physical examination:
GCS 456
BP: 110/70 mmHg
PR: 63 bpm
RR: 20 tpm
Tax: 36.7 degree celcius
Lacrimation, pupil miosis
pupil midriasis 8mm/8mm
Laboratory:
Leucocyte 17300

PL

Idx

3. Trauma occuli 3.1 dt no 1

chemis D/S

PDx
Funduscopy
Ophtalmosc
opy

PTx
Irrigation ODS with RL 2 lt until PH
normal limit
Patching in 8 hours
Tobromycin 8x 1 gtt ODS
Repitel 4x1 gtt ODS
Vitamin C 2x500 mg

Pmo
Monitoring:
S, VS
DL

Education
Disease, treatment, prognosis

Condition this morning

BP: 110/70 mmHg
PR: 65 bpm
RR: 18 tpm
Tax: 37.00 Celcius
UOP 25cc/hour

Thank You