MORNING REPORT Ward 26

Sunday, November 3rd 2013 CoAss On-Duty: Rifqi Aulia Destiansyah Arif Ismail Moderator : dr. Rully Rosandi, Sp.PD

Summary of Data Base

Female/35 y.o./Heteroanamnesa by patient s husband and mother. Chief complaint : decrease of consciousness Patient was found with altered of conscious level at her room at 03.00 AM (+/- 3 hour before admitted to the hospital). Patient was brought to the Baptis Hospital, Batu before brought to the Saiful Anwar General Hospital, Malang. This decrease of consciousness suddenly occured. Before this, she called her friend and told her that she wants to die. Patient has been diagnosed with Psychiatric problem since 5 years ago when she gave birth to her 2nd child. Patient has a introvert personality and has been consulted to Psychiatric departement. The Psychiatrist gave her the combination of Amitriptilin, Alprazolam, Lorazepam, Clozapin and took it regularly. Patient was in decrease of consciousness after took the medicine on 10.00 PM and between on 11 PM and 11.30 PM she was confused and raved.

Summary of Data Base

Patient always feel that she could not and didnt want to eat (decrease of appetite), couldnt sleep, and didnt want to drink since one month ago. She has been married for 13 years and when she got a problem she didnt want to share it to the other people . Patient had a history of try to suicide three times and she always use the same way which is took her psychiatric medication with an enormous number of it.

History of past illness: History of family: History of social and environmental : -She is a housewife and her husband is a civil officer -Have 2 children -Alcoholic consumption -, Smoking history -

Physical examination
BP = 120/80 mmHg PR = 108 bpm (ER) 90 bpm (W. 26) An -/- ; ict -/Pupil isocor 3mm/3mm Light reflex +/+ JVP R+0 cm H2O Ictus invisible, palpable at ICS V MCL Sinistra S1 S2 single, murmur (-) RHM = Sternal Line Dextra. LHM = Ictus Symmetric, SF D=S, Vesicular breath sound, no rhonchi, no wheezing Flat, soefl, liver span 8cm, traubes space tympani, bowel sound (+) N, shifting dullness (-) No Edema Warm acral CRT <2 Pathologic reflex : BCOGS (-) RR = 18 tpm GCS 1x5 with mayo Tax : 36.5 0C

General appearance : looked severely ill Head

Neck Chest Heart

Lung Abdomen Extremities

LABORATORY FINDING
: Lab
Leucocyte Hemoglobine RBC MCV MCH MCHC Trombocyte Differential count Result 03/11/2013 20,74 14,10 4,82 84,90 29,30 34,50 329000 Normal Value 3.500 10.000 11.4-15.1 4.0-5.0 80-93 27-31 32-36 142000-424000

0,1/0/87,3/6,8/ 0-4/0-1/515,6 67/25-33/2-5

Ureum
Creatinin RBS

18,60
0,84 138

16,6-48,5
<1,2 <200

URINALYSIS
Result SG PH Leucocyte 1,030 6,0 1+ 10 x Epithelia Cylinder Hyaline Granular Leukocyte Erythrocyte 2,4 Result

Nitrite
Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin Bacteria

2+

40 x
52.2x10 Eritrosit Leukocyte Crystal coccus/stab 34,1lpb 23,3 lpb -

Lab
SGOT SGPT Albumin PPT aPTT

Result 03/11/2013 12 8 4,68 Normal Normal

Normal Value 0-40 0-41 3,5-5,5

Lab Na K Cl Ca Phosphor 137 3,04 105 9,1 4,2

Result 03/11/2013
mmol / L mmol / L mmol / L mg/dL mg/dL 3.5 5.0

Normal Value
136 145 98 106 7,6-11,0 2,7-4,5

Lab Blood Gas Analysis pH pCO2 pO2 Bicarbonate Base Excess O2 Saturation 7,41 37,2 109,7 23,6 -1,3 97,3

Result 03/11/2013

Normal Value

7,35-7,45 mmHg mmHg mmol/L mmol/L % 35-45 80-100 21-28 -3 or +3 >95

ECG
Sinus rhythm, HR 107 bpm

Frontal axis: normal

Horizontal axis : normal PR interval 0.12 QRS complex: 0.08 QT interval: 0.24 Conclusion: sinus tachycardia with HR 107 bpm

Chest X-Ray
AP position, symmetric, KV enough, enough inspiration

Soft tissue normal, Bone normal

Trachea in the middle Hemidiaphragm D and S are domeshape

Phrenico costalis angle D/S sharp

Pulmo D/S: normal Cor: site N, size CTR <50%, shape cardiac waist normal

Conclusion : normal CXR

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

PED

Female/ 33 yo Find Unconciousness Hystory of Phsyciatric problem Drunk Medicine contain Alprazolam 3,70mg, amithripthyllin 187,5mg,Clozapine 370mg, Lorazepam 11,25mg according 15 capsul PE: BP=120/ 70mmHg PR =82 bpm RR =18 tpm Tax :36,5 0C GCS: 1x5 Pupil Isocor 4cm Corneal rfleks + Lab: Leuko:20,740

1.Decre 1.1, ase of Intoxication Conciou Trycyclic anti sness

depresan 1.2,Intoxicati on Benzodizepin e

Check the Lavage Fluid

O2 8-10 Lpm NRBM Insert NGT Gastric lavage and gave Norit ( Activated Charchaol ) 50 gram ( via NGT ) Cont with fluid diet 6x200cc IVFD Nacl 0,9% 20 Dpm Inj Omeprazole 1x40mg

GCS VS Subj Urine produ ction per 24 hour

Carful and aware of behav ior chang e of patien t

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

PED

Female/ 33 yo 2.Psyciatr 2.1, Diagnose With ic Tentament Psikiatric problem Problem Suicide since 5 years ago, 2.2, Fell Of Afraid, Episodic Worried and Depresion Decrease of appetite, without any other causes Routinly Consume Alprazolam , Amithripthyllin,Cloza pine, Lorazepam insert at capsul

----

Consult to the Psyciatric department

VS Subj GCS

Carful and aware of behav ior chang e of patien t

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

PED

Female/ 33 yo Decrease of apetite since one month, Lab: K:3,04

3.Hypoka lemia

3.1,dt Low intake 3.2,dt GI Loss

-----

Oral : KSR Tablet 3x500mg

Subj VS SE

Take High Kaliu m Meal

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

PED

Female/ 33 yo Lab: Leuko:20,740 UL: SG: 1.030 PH: 6,0 Erithrocyte : 34,1High power Field Leucocyte:23,3High Power field

4.U.T.I Urinary Tract Infection

4.1, Upper U.T.I 4.2,Lower U.T.I

Urine Culture and sensitivit y test,

Inj Ciprofloxacin 2x400mg Subj VS (IV)

Urinar y produ ct/24 Hour

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

PED

Female/ 33 yo Leuko:20,740

6.Leucoc ytosis

6.1,Reactiv e dt Drug induce 6.2,U.T.I

Repeat CBC ( Complet e blood Count ) Repeat Urinalysi s

Confirm diagnose

Subj VS Urine Produ ction

Problem Analysis
Psyciatric problem Decrease of Conciousness

Decrease of appetite

Drug intoxication

Leucocytosys Hipokalemia UTI( Urinary tract Inf )

Risk Factor Drug Intoxication:

1. Self Medication

2. Tentament Suicide
3. Addiction 4. Neglected teraphy by the docter

Risk Factor UTI ( Urinary Tract Infection ):

1. Female

2. Dehydration
3. Urolithisis

Manageman Analysis
Emergency: O2 8-10 Lpm NRBM Insert NGT Gastric lavage per 8 hour Oral: Norit ( Activated Charchaol ) 50 gram ( via NGT ) Urgency: Fluid diet 6x200cc IVFD Nacl 0,9% 20 Dpm ( Line 1) Inj Omeprazole 1x40mg (IV ) Inj Ciprofloxacin 2x400Mg (IV) Non-urgency: Oral: KSR tablet 3x1 ( via NGT )

CONDITION THIS MORNING

S: Conciousnes
GCS: 456 BP: 130/90 HR: 103tpm RR: 20 tpm Urine Production: 100cc/hour

Thank you