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Morning Report

SUMMARY OF DATA BASE

Mr. R / Male/ 25 yo/ W 27

Chief Complain : Blurred vision

History of present illness:


(Heteroanamnesa : patients brother)

Patient suffered from blurred vision and


decrease of counsciousness since 2 days
before admission in RSSA after he drank
some alcohol beverages (red label.
Patient complained that he had nausea
and severe vomiting after drinking the
alcohol. 1 days before admission patient
didnt look because very blurred vision.
The father took the patient to the hospital.
Patient had history of consuming
alcohol since 7 years ago when in senior
high school.
There is no history of drug abuse.
There is no history of hypertension and
Diabetes Mellitus previously.
Family history of any diseases (-)
PHYSICAL EXAMINATION
BP = 120/70 PR = 78 bpm, RR = 20 bpm Tax : 36 C
mmHg strong, regular
General appearance looked GCS 456
moderately ill
Head Anemic - Icteric - Visus 1/300 . Light
reflex (-)
Neck JVP R + 0 cm;
30
Thorax: Ictus invisible, palpable at ICS V MCL Sinistra
Cor: LHM ictus
RHM SL Dextra
S1, S2 regular, with no murmur
Symmetric, SF D = S, v v Rh - - Wh - -
Lung: vv -- --
vv -- --
Abdomen Flat, soefl, liver span 10 cm, troube space tympani, BS
(+) N
LABORATORY FINDING
Lab Value Lab Value
Leukocyte 15.000 3.500- Diff count 0,1/0,3/7
10.000/L Eosinofil/ba 9,4/11,9/
sofil/netrofil/ 8,3
limfosit/mon
osit
Haemoglobin 19.40 11,0-16,5 Kalium 2,5
e g/dl
PCV 54.40 35-50% Chlorida 100
Trombocyte 193.00 150.000-
0 390.000/L
MCV 87,30 Ureum 58,9 10-50 mg/dL
MCH 31,10 Creatinine 1,34 0,7-1,5 mg/dL
BLOOD GAS ANALYSIS
BGA Value
( 4L O2 )

PH 7,33 7,35-7,45

PCO2 27,3 35-45

PO2 79,5 80-100

HCO3 14,4 21-28

O2 saturation 94,8% > 95%

Base Excess - 11,8 -3 until +3

Conclusion Metabolic acidosis


ECG
CXR
CUE AND CLUE PL IDx PDx PTx PMo
male/25 yo 1. 1.1.Intoxicat Ethanol O2 2-4 L/NC Subjectiv
Decrease of Alkohol ion blood IVFD NS 0,9%: D5 % : e
counsciousness intoxicati methanol level, 20 tpm BP,GCS,
consume on mixed metan Gastric lavage PR, RR,
alkohol ethanol ol Loading ethanol 50 % BGA,
Blurred vision 1.2.Intoxicat blood (75 ml) in D5% RBG,urin
Physical ion ethanol level solution via NGT e
examination: Continued 0,5 producti
Visus 1/300, ml/kgBW for every 2 on
light reflek (-) hours for 4 days
GCS : 456
BP: 120/70
mmhg
PR: 78 bpm
RR: 20 bpm
Laboratory:
BGA: metabolic
acidosis
PH: 7,33
HCO3: 14,4
mmol/l
CUE AND CLUE PL IDx PDx PTx PMo

Male/19 yo 2. Blurred 2.1Due to Fundusco Tiamin 3 x100 mg iv VS,


Blurred vision vision no 1 py Dexamethason inj subj
History of (toxic refer to 1x40 mg (iv). ectiv
consume alcohol optic optalmolo e
neuropat gic
hy) departme
nt
Male / 19 yo 3. Azotemia 3.1 CCT, Equal fluid balance Ur,C
Laboratory prerenal abdominal infus NS r
Ureum: 58,90 dt usg 20cc/kgbw/hour
Creatinin: 1,34 inadequat
Leukoasit: e renal
15.000 perfusion
(dehidrati
on)
3.2 renal
3.2.1 AKI
stage III
Thank you