MR 17042015 IPD Christian.pptx
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Transcript of MR 17042015 IPD Christian.pptx
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