Morning ReportApril 17th 2015

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 wifeChief 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: -

Social history: he is married, having 3 children, he is a farmer, history of smoking 12 bars/day since youth.

.

Physical ExaminationBP = 110/70 mmHg PR = 63 bpm RR = 20 tpm Tax : 36.7°C

General appearance looked moderately ill GCS 456 Looked normoweight

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

Inserted NGT

Neck JVP R + 1 cmH2O 30 degree, lymphnode enlargement -

Chest Heart: Ictus visible and palpable at ICS V at MCL SinistraLHM ~ ictusRHM ~ PSL DS1, S2 single, murmur (-)

Lung: Symetric, Rh - - Wh - - V V S S - - - - V V S S - - - - V V S S

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

Extremities Warm acralEdema (-)UOP 20cc/hour

LABORATORY FINDINGSLab Value Lab Value

Leuco 17300 4000-11.000/µL Ur 21.5 16,6-48,5 mg/dL

Diff count 0.2/0.2/84/12.9/2.7

0-4/0-1/51-67/25-33/2-5 %

Cr 0.77 < 1,2 mg/dL

Hb 13.6 11-16,5 g/dL RBS 98 <200 mg/dL

MCV 76.70 80-93 fl Na 138 136-145mmol/l

MCH 26.70 27-31pg K 3.85 3,5-5,0 mmol/l

PCV 39.1 40-47 % Cl 111 98-106 mmol/l

Thrombocyte 235000 150-450x103/µL

SGOT 20 11-41U/L

SGPT 19 11-41U/L

Lab Value Lab Value

Urinalysis 10 x

SG >1.030 Epithelia 3.2

PH 5.5 Cylinder -

Leucocyte - Hyaline -

Nitrite - Granular -

Protein Trace Leukocyte -

Glucose - Erythrocyte -

Erythrocyte - 40 x

Erythrocyte -

Keton urine - Leukocyte 4.0

Urobilinogen - Crystal -

Bilirubin - Bacteria 58.7

URINALYSIS

BLOOD GAS ANALYSISpH 7,31 7,35-7,45

pCO2 38.1 35-45 mmHg

pO2 27.6 80-100 mmHg

HCO3 19.2 21-45 mmol/LBE -7.4 (-3) – ( +3) mmol/L

O2 saturation 48.9 >95 %

Hb 13.3 g/dL

Temperature 37.0

BGA conclusion Vena sampling

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 Idx PDx PTx Pmo

Male/ 48 yo/ w26Anamnesis:Nausea and vomitingLacrimationPain in his eyesExposed by pesticideHistory got Sulphas atrophin at PHCPhysical examination:GCS 456BP: 110/70 mmHgPR: 63 bpmRR: 20 tpmTax: 36.7 degree celciusLacrimation, pupil miosis pupil midriasis 8mm/8mm

Laboratory:ECG : sinus rhythm with heart rate 64 bpm

1. Orghanophosphate intoxication

Toxicology

O2 10 lpm NRBMFastingInsert NGTInsert catether urinationInj sulphas atrophine 1 mg/6 hours until the PR>100x/minutesInj lansoprazole 1x30 mg ivIVFD NS:D5% = 2:1 + 20 dpm

Monitoring:S, VS EducationDisease, treatment, prognosis

CUE AND CLUE PL Idx PDx PTx Pmo

Male/ 48 yo/ w26Anamnesis:Nausea and vomitingLacrimationPain in his eyesExposed by pesticideHistory got Sulphas atrophin at PHCPhysical examination:GCS 456BP: 110/70 mmHgPR: 63 bpmRR: 20 tpmTax: 36.7 degree celciusLacrimation, pupil miosis pupil midriasis 8mm/8mm

Laboratory:Leucocyte 17300

2. Leucocytosis 2.1 dt no 1 Inj ceftriaxone 2x1 g iv Monitoring:S, VSDL EducationDisease, treatment, prognosis

CUE AND CLUE PL Idx PDx PTx Pmo

Male/ 48 yo/ w26Anamnesis:Nausea and vomitingLacrimationPain in his eyesExposed by pesticideHistory got Sulphas atrophin at PHCPhysical examination:GCS 456BP: 110/70 mmHgPR: 63 bpmRR: 20 tpmTax: 36.7 degree celciusLacrimation, pupil miosis pupil midriasis 8mm/8mm

Laboratory:Leucocyte 17300

3. Trauma occuli chemis D/S

3.1 dt no 1 Funduscopy Ophtalmoscopy

Irrigation ODS with RL 2 lt until PH normal limitPatching in 8 hoursTobromycin 8x 1 gtt ODSRepitel 4x1 gtt ODSVitamin C 2x500 mg

Monitoring:S, VSDL EducationDisease, treatment, prognosis

Condition this morning

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

Thank You