Morning Report

Coass Incharge
Amelia Fitra Khasanah
M. Aufifillah
Monica Sari Devy

Tuesday, June 14th 2017

Supervisior
dr. Rina , SpPD
Mr. S/76 yo/Ward Dahlia II
HISTORY TAKING : alloanamnesis with his family
CHIEF COMPLAINT : Vomiting (After Drinking Insectisida)
HISTORY OF PRESENT ILLNESS :
• Patient presented with the chief complaint vomiting 1 hours before admission, his family
told that he after drinking “Obat Padi”. “Obat Padi”’s name is Killer. He vomited 1 time,
didn’t projectile, contain fluid with white colour,+ 2 glass. He also complained about
headache and weakness. he took ½ glass of “obat padi” after frustrating, because he
complained difficult to defecation since 3 days ago. He usually defecation 1x/day.
• before patient complained difficult to defecation, he eat and drink normally. His family
bring him to General Practioner 1 day before admission because of his constipation, and
he got amoxicillin, tablet for constipation but family forgot drug’s name and syrup for his
stomach (the colour is yellow) but his family forgot the drug’s name. He had got
medication but he didn’t feel any better, then he felt hopeless and want to suicide with
drinking “obat padi”.
• His family said that he felt palpitation with cold sweating after drink “obat padi”
There were no history of fever, flushing, itching, hoarseness nor seizure
PAST MEDICAL HISTORY :

He got stroke 5 month ago. DM -, HT -

SOCIAL HISTORY : Patient is a husband who has two children . He

didn’t work. Patient is ex-smoker since 10 years ago.

FAMILY HISTORY :

There is no family member with same complained

 Physical Examination
Looked normoweight
General Appearance: looked severe ill

HR : 114 bpm regular

GCS: 456 110/70 mmHg RR : 26 tpm Tax : 36.3 °C
strong
Head Anemic conjunctiva (-) icteric sclerae (-), pupil pinpoint, mounth/breath: drug odor
Neck JVP: R + 0 cm H2O in 30° position Lymphonode enlargement -
Wall Chest expansion symmetric

Chest Ictus invisible, palpable ICS V 1 cm lateral MCL S Trill: - Heaves: -

Heart RHM ~ SL D LHM ~ ictus
S1 and S2 single, no murmur
Stem Fremitus D=S S S v v Rh - - Wh - -
SS v v - - - -
Lung
SS v v - - - -
Percussion : dullness at basal lung dextra and sinistra
rounded, bowel sound decreased, epigastrial tenderness (-), liver span 8 cm, Traube’s
Abdoment
space tympani

Warm, edema -/-

Extremities
-/-
 LABORATORY FINDING (Juny 11 2017) Mr.S
Lab Value (Normal)

Hemoglobin 16.4 12-18 g/dL

leukocyte 20.2 4.5-11.0 x 103/µL

Trombocyte 348000 150.000– 450.000/µL

MCV 94 76-96 fl

MCH 30.7 26-35 pg

 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring
Mr.S/76 yo/w.Dahlia II 1. Intoxication 1.1 Intoxication Gastric Lavage O2 4 lpm (NC) Subjective
AX : Insectiside Organophospat Bed rest Vital Sign
-After drinking “Obat semifowler Urine production
Padi”/”Kiler”
position Pupil diameter
-he took ½ glass of
“obat padi” Decontamination
-nausea and vomiting Gastric Lavage PEdu:
-feel palpitation and Liquid diet via Disease
cold sweating NGT Underlying disease
IVFD NaCl 0.9% 20 Treatment Prognosis
PE : tpm
BP : 110/70 mmHg
RR : 26 tpm
Inj. Atropin
PR : 114 tpm
Pupil pint point 1mg/3menit until
Mounth/breath: drug’s midriasis-> max
odor dose: 50mg
LF : Inj
Leucocyte : 20.200 Metoclopramide
3x10 mg
Inj Lansoprazole
1x30mg
Inj. Ceftriaxone
2x1g
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring
Mr.S/76 yo/w.Dahlia II 2. Constipation Liquid diet via Subjective
AX : NGT Vital Sign
-difficult to defecation Diet High Fiber Urine production
about 3 days
-He usually defecate
1x/day Lactulosa 3x1 ct PEdu:
PE : Disease
Abdomen : rounded, Underlying disease
bowel sound Treatment Prognosis
decreased
LF :
 CUE AND CLUE Problem List Initial Diagnosis Planning Diagnosis Planning Therapy Planning Monitoring
Mr.S/76 yo/w.Dahlia II 3.Geriatric Subjective
AX : Depresion (GDS : Zoloft 1x12.5mg-> Depression level
he took ½ glass of 10) increase the dose
“obat padi” after
if no improvement Education: Lifestyle
frustrating,
-he felt hopeless and changes increase
want to suicide with Psychotherapy -> physical activity,
drinking “obat padi” consul to discover new
psychiatry hobbies, regular
Geriatic Depression visits with family and
Scale : 10 friends, get enough
sleep, eat a balanced
diet
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