Mr Hypersensitivity

7/28/2019 Mr Hypersensitivity

1/18

MORNING REPORT

16 APRIL 2013


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Name : IMKS

Sex : Male

Age : 39 yrs old

Nationality : Indonesia

Job : Private Sector

Religion : Hindu

Marital status : Married

Address : Br Pegambangan, Batubulan, Gianyar

Date of admission: 15/04/2013

Time of admission: 13.00

Patients Identity


3/18

ANAMNESISChief Complaint : Itchiness

Present History : Patient came to the emergency department complaining

itchiness since 1 day BATH. Itchiness claimed to be present

whole over the body and its told to be very disturbing until

patient could not conduct his daily activities.

This complain started at 17.00 oclock one day BATH. His skin

became reddish with patches soon after he felt the itching

Complain of itchiness arise after taking medication such as

Paracetamol and Ibuprofen. This medication was taken 2 days

before BATH.


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Present History :

Complains such as having watery and red eyes. palpitation,breathlessness, nausea, vomiting, abdominal discomfort or

collapse was denied by the patient.


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ANAMNESIS

Past Medical History : Patient have not experience the same complain before.

History of drug or food allergy was denied by the patient

History of asthma, dermatitis atopic or rhinitis allergic was

denied by the patient. History of heart disease, hypertension, diabetes were denied by

the patient.

Medication History :

Paracetamol and Ibuprofen was given for the past 2 days BATH


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ANAMNESIS

Family History : None of the patients family members have the similar complain

Patients mother suffers from asthma since she was a teenager

History of diabetes , cardiovascular disease, hypertension were

denied.

Social History :

Smoking (+). 10 butts of cigarette per day

Alcohol consumption were denied


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Physical examination

Appearance : Mildi ill

Level of conciousness : E4V5M6

Blood pressure : 130/90 mmHgTemperatur axilla : 36,7OC

Pulse rate : 84x/min, reguler

Respiratory rate : 20 X/min thoracoabdominal type

Eyes : Anemia +/+, ict -/-, RP +/+ isocoric , oedem

palpebra - -/- - watery eyes -/-

ENT : Tonsil, Pharynx, tongue WNL

Neck : JVP PR0 cm H2O, enlargement (-)

Chest examination

Heartinspection : Ictus cordis: not seenpalpation : Ictus cordis : not palpablepercussion : Upper border : ICS II

Right border : Right PSLLeft border : ICS 5 MCL Sinistra

auscultation : S1 S2 single regular, murmur (-)


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Lung examination

inspection : symetric

palpation : vocal fremitus is normalpercussion : sonor / sonor

auscultation :Ves +/+ , Rh -/- , wh -/-

Abdomen

inspection : distention (-)

auscultation : normal bowel sounds

palpation :

liver : unpalpable

spleen : unpalpabletenderness: -

ballotement: -

percussion : tymphani

Physical examination


9/18

Extremity : Pitting edema - -/ - - warm + + /+ +

Others : Macula Erytematous all over his body with various size ( + )


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11/18

Parameter Result Unit Remarks Referencerange

WBC 6.223 103/L 4,1 10,9

-Ne 4.337% 103/L 2,5 7,5

-Ly 1,185% 103/L 1,0 4,0

-Mo 0,40% 103/L 0,1 1,2

-Eo 0.27 % 103/L 0,0 0,5

-Ba 0.01 % 103/L 0,0 0,1

RBC 4.709 106/L 4,00 5,20

HGB 12.6 g/dL 12,00 16,00

HCT 40,24 % 36,0 46,0

MCV 94.3 fL 80,0 100,0

MCH 32.6 pg 26,0 34,0

MCHC 34.6 g/dL 31,0 36,0

RDW 11,19 % 11,0 14,8

PLT 327,0 103/L 150 440

MPV 6.8 fL 0,0 100,0

COMPLETE BLOOD COUNT


12/18

BLOOD CHEMISTRY PANEL

Parameter Result Remarks Reference rangeSGOT 28, 32 11-33

SGPT 32, 54 11-50

BUN 14, 82 10-23

Creatinin 0, 78 0.5-1.2

BS 104,00 70,00-140,00


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Sinus rhythmHR :75x/mnt, reguler

Axis : Normal

P wave : Normal

PR interval : Normal

ORS complex : Normal

ST-T segment changes: (-)

Result: Normal ECG

ECG


15/18

Assesment

Hypersensitivity Reaction e.c susp drugs

(Ibuprofen, Paracetamol)


16/18

Treatment

Hospitalized IVFD NaCl 0,90 20 dpm

Methylprednisolone 2 x 62.5 mg

Dipenhydramine 3 x 10mgStop suspecting substances


17/18

Diagnostic Planning : IgE total

Monitoring: Vital Sign and Complaints

Planning


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