MORNING REPORT

CASE

16th July, 2012

PATIENT’S IDENTITY
Name : SA
Age : 17 yo
Gender : Female
Ethnicity : javanese
Religion : Islam
Occupation: employee
Address : Sumber Tumpuk Pasuruan
ToA : 14th July 2012 02.00 pm
ANAMNESIS

 Chief complain :
vommit
 Present history :

 Patient came with chief complained of

vommiting since 30 minutes BATH, after
consumed 28 tablets of bodrex which was
mixed with a bottle of kratingdaeng and 2
bottles of sprite at 11.00 am.
 The colour of vommit was light orange and
was mixed with black colour. The vommit was
complained more than 10 times, average a
half of aqua glass each vommit. Nausea
happened prior to vommit. Patient also
complained fatigue.
 Patient also complained of epigastrial pain
which came suddenly after consumed bodrex.
The pain was felt throbbing and didn’t
recovery with changing position
 Patient also complained shortness of breath
and headache, which came together 1 hour
after she consumed bodrex. These complained
make she felt weak.
 Defecation and urination was normal before
she consumed bodrex.
 Past illness history
 patient had no history of gastritis or other
gastrointestinal disease
 Patient had no history of consumed jamu and
NSAID
 Social History :
 Patient had no history of alcohol consumption
and smoking.
 Meal pattern was iregularly after she had
problem with her boyfriend.
 PHYSICAL EXAMINATION
General appearance : severely ill
Level of consciousness : CM
GCS : E4V5M6
VAS : 6/10
Vital Sign:
 BP : 110/70 mmHg
 RR : 22 x/min
 PR : 100 x/min
 tax : 36,5°C
BW : 50 kg
BH : 155 cm
BMI : 20,8 kg/m2
Eyes : conj. Pale (-/-); icterus (-/-);
Rp +/+ isocoric, oedema palp. (-/-)

ENT : Tonsils T1/T1; pharyngeal hyperemia (-);

tongue normal; lip cyanosis (-)

Neck : JVP RP 0 cmH2O;

lymph node enlargement (-)
Thorax : Simetris, retraction (-)
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)

Po
Inspection : Symetric (static and dinamic)
Palpation : VF N/ N
Percussion : dull/dull
Auscultation : Bronchovesikular + / + , Rh -/-, wh -/-
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tymphany
Palpation : liver, spleen unpalpable
(pain on epigastrium)

Extremities: Warm +/+; edema -/-

+/+ -/-
 Complete blood count
Parameter Result Unit Remarks Reference range
WBC 8,00 103/μL 4,5 – 11,00
-Ne 54,80% 4,40 103/μL 47,00 – 80,00
-Ly 36,00% 2,90 103/μL 13,0 – 40,0
-Mo 8,70% 0,70 103/μL 2,00 – 10,00
-Eo 0,10% 0,00 103/μL 0,00 – 5,00
-Ba 0,40% 0,00 103/μL 0,0 0 – 2,00
RBC 5,17 106/μL 4,50 – 5,90
HGB 15,20 g/dL 13,50 – 17,50
HCT 45,00 % 41,00 – 55,00
MCV 86,90 fL 80,00 – 100,00
MCH 29,50 pg 26,00 – 34,00
MCHC 33,90 g/dL 31,00 – 36,00
RDW 13,70 % 11,60 – 14,90
PLT 317,00 103/μL 150,0 – 440,0
MPV 6,60 fL L 6,80 – 10,00
 Blood chemistry panel

Parameter Result Unit Remarks Reference range

SGOT 17,35 U/L 11,00 – 33,00
SGPT 10,21 U/L L 11,00 – 50,00
Albumin 4,651 U/L H 3,20 – 4,50

BUN 6,714 mg/dL L 10,00 – 23,00

Creatinine 0,558 mg/dL 0,50 – 1,20
Na 136,30 mmol/L 136,00 – 145,00
K 2,814 Mmol/L L 3,5 - 5,1
Bilirubin total 0,34 Mg/dl 0,30 – 1,10
Bilirubin indirek 0,20 Mg/dl <0,8
Bilirubin direk 0,14 Mg/dl 0,00-0,30
Alkali fosfatase 81,32 U/L 42,00-98,00
Blood Gas Analysis

Parameter Result Unit Remarks Reference range

pH 7,433 - 7,35 – 7,45
pCO2 16,40 mmHg L 35,00 – 45,00
pO2 126,40 mmHg H 80,00 – 100,00
HCO3- 10,70 mmol/L L 22,00 – 26,00

TCO2 11,20 mmol/L L 24,00 – 30,00

BE(B) -13,60 mmol/L L -2 – 2
SO2c 98,70 % 95,00 – 100,00
ECG
ECG
 Rhythm sinus
 Axis N
 ST-T change (-)
 Conclusion : sinus tachycardia (116x/min)
ASSESMENT

 Intoxication acetaminophen
 Erosive gastritis e c drug induced DD mallory tears
PLANNING
 Therapy
 hospitalized
 IVFD Na CL 0,9% 20dpm

 NGT  GC @ 12 hours

 MgSO4 30mg

 Norit 10 tablets

 N – acetylcistein 150mg/kgBW in 200cc D5% in 1 hour 

50mg/kgBW + 500cc D5% in 4 hours  50 mg/kgBW +
500cc D5% in 8 hours
 Pantoperazole 3 X CI

 Antacida 3 X CI

 Sucralfat 3 X CI

 Ondancentron 2,5mg iv
 Pdx
 Acetaminophen level
 EGD

 Monitoring
 Vital
sign
 Complaints
THANK YOU