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April 17 2015
th
Coass in charge :
Cristian Rajagukguk
Rudi Rakhmad H
Supervisor :
dr. Laksmi S, SpPD-KEMD
Physical Examination
BP = 110/70 mmHg
PR = 63 bpm
RR = 20 tpm
Neck
Chest
GCS 456
Tax : 36.7C
Looked normoweight
Inserted NGT
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
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
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
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
PL
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
PL
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
PL
Idx
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
Thank You