Professional Documents
Culture Documents
Occupation
Address Marital status
TA
: SY : Male : 33 years old : Indonesia : Islam : Employee :Jl. Gang Lebah No. II Denpasar : married :22 August 2012 (14.00 p.m)
ANAMNESIS
Chief Complain: Vomiting Present History: Patient came with chief complaint of vomiting since 1
day before admission. Vomit contain food that patient eat before. Vomit about three times and volume was of glass every vomit. Patient also complained about nausea. Bloody vomit also denied by patient.
before admision. The visual like cloudy vision and when patient go to hospital, patient cant see anything Patient has an history drink alcohol 3 days BATH, Patient also complained about breathlessness 1 day BATH. History of fever was denied by patient. Stool and micturition was normal.
Past History
Patient never felt the same complain like this before. History of allergic, Heart ds, Asthma, Lung TB were
denied.
Family History
History of heart ds, Asthma, Lung TB, in family
member were denied Social History He drank alcohol 3 days BATH with his friend, but patient forget the brand.
Physical examination
: moderately ill : Somnolen (E4V4M5) : 0/10 : 110/70 mmHg : 100 bpm : 22 bpm : 36,5 0C : 170 cm : 65 kg : 22, 49 kg/m2
Eyes
Ear: secret (-). Nose: secret (-), hyperemia (-) Throat: pharing hyperemia (-), T1/T1. Tenderness (+) JVP 0 cmH2O Gland enlargement (-)
Neck
Thorax Cor
I : Ictus cordis unseen Pa : Ictus cordis palpable Pe : UB (ICS II), RB (PSL dextra), LB (MCL sinistra ) Aus : S1S2 single, regular, murmur (-)
Po
I Pa Pe Aus : Simetrically (static & dinamic) : Vocal fremitus N/ N : Sonor/ Sonor : Vesicular +/+, Rhonki-/+, Wheezing -/-
ABDOMEN
I Aus Pa Pe : dist (-) : Bowel sound (+) normal : tenderness (-), H/L unpalpable, : Tympanic (+)
EXTREMITIES
Warm (+), oedema (-)
Parameter
Pemeriksaan penunjang
Resul t Unit Remarks Paramater
Result
Unit
Remar ks
WBC
NEUT LYMPH
16,68 103L
89,60 % 103L 7,10 % 103L
Hematokrit
Platelet MCV MCH
53,90 %
511 103L 85,50 fL 28,60 pg
MONO
EOS BASO RBC Hemoglobin
2,60 % 103L
0,10 % 103L 0,10 % 103L 6,05 106L 18,00 g/dL
Chemical COUNT
Parameter BUN Creatinin SGOT SGPT RBG Cloride Result 25,00 1,34 30,00 88,00 110,00 95,22
PH
PCO2 P02 HCO3 BE SO2 NA K
7,1
10 165 3,20 -26,30 99 131 7,3
Chest X-Ray
CTR 50% Pulmo: infiltrat (-), nodule (), bronchovesicular patern normal Costrophrenicus angle is left and right sharp Left and right diaghfarma was normal Conclusion: cor and pulmo was normal
Assessment
Intoxication methanol
Acidosis metabolic Hipercalemia
PLANNING
Theraphy
HD Cito IVFD Nacl 0,9% 20 tpm Thiamin inj
Monitor
AGD Kalium post HD
Thank you