CASE REPORTAugust, 22st 2012

IDENTITYName : SYGender : MaleAge : 33 years oldNationality : IndonesiaReligion : IslamOccupation : Employee Address :Jl. Gang Lebah No. II

Denpasar Marital status : marriedTA :22 August 2012 (14.00 p.m)

ANAMNESISChief Complain: VomitingPresent History:Patient came with chief complaint of

vomiting since 1 day before admission. Vomit contain food that patient eat before. Vomit about three times and volume was ¾ of glass every vomit. Patient also complained about nausea. Bloody vomit also denied by patient.

Patient also complained about blurr vision since 1 day before admision. The visual like cloudy vision and when patient go to hospital, patient can’t see anything

Patient has an history drink alcohol 3 days BATH,

Patient also complained about breathlessness 1 day BATH.

History of fever was denied by patient. Stool and micturition was normal.

Past HistoryPatient never felt the same complain like this before. History of allergic, Heart ds, Asthma, Lung TB were

denied.

Family HistoryHistory of heart ds, Asthma, Lung TB, in

family member were deniedSocial HistoryHe drank alcohol 3 days BATH with his

friend, but patient forget the brand.

Physical examinationGeneral appearance : moderately illLevel of consciousness : Somnolen (E4V4M5)VAS : 0/10BP : 110/70 mmHgHR : 100 bpmRR : 22 bpmTemp. Ax : 36,5 0CHeight : 170 cm BW : 65 kgBMI : 22, 49 kg/m2

Conjuntival pallor -/-Icterus -/-, redness -/-PR +/+ isochoric

Ear: secret (-).Nose: secret (-), hyperemia (-)Throat: pharing hyperemia (-), T1/T1.

Tenderness (+)JVP ± 0 cmH2OGland enlargement (-)

Eyes

ENT

Neck

Thorax

Cor• I : Ictus cordis unseen• Pa : Ictus cordis palpable• Pe : UB (ICS II), RB (PSL dextra), LB (MCL

sinistra )• Aus : S1S2 single, regular, murmur (-)

Po • I : Simetrically (static & dinamic)• Pa : Vocal fremitus N/ N• Pe : Sonor/ Sonor• Aus : Vesicular +/+, Rhonki-/+, Wheezing -/-

ABDOMEN• I : dist (-)• Aus : Bowel sound (+) normal• Pa : tenderness (-), H/L unpalpable, • Pe : Tympanic (+)

EXTREMITIES• Warm (+), oedema (-)

Pemeriksaan penunjangParameter Res

ult

Unit Remarks

WBC 16,68 103µL H

NEUT 89,60 % 103µL

LYMPH 7,10 % 103µL

MONO 2,60 % 103µL

EOS 0,10 % 103µL

BASO 0,10 % 103µL

RBC 6,05 106µL

Hemoglobin 18,0

0

g/dL

Paramater Result Unit Remar

ks

Hematokrit 53,90 %

Platelet 511 103µL

MCV 85,50 fL

MCH 28,60 pg

Chemical COUNTParameter Result

BUN 25,00

Creatinin 1,34

SGOT 30,00

SGPT 88,00

RBG 110,00

Cloride 95,22

PH 7,1

PCO2 10

P02 165

HCO3 3,20

BE -26,30

SO2 99

NA 131

K 7,3

Chest X-RayCor: within normal limite,

CTR 50%Pulmo: infiltrat (-), nodule

(-), bronchovesicular patern normal

Costrophrenicus angle is left and right sharp

Left and right diaghfarma was normal

Conclusion: cor and pulmo was normal

AssessmentIntoxication methanolAcidosis metabolicHipercalemiaToxic optic neuropathy

PLANNINGTheraphy MonitorHD CitoIVFD Nacl 0,9% 20 tpmThiamin injCa Glukonas 3x1 ampNebulizer salbutamol

20 mg D 40% 100 cc+ D 10 %

100 cc+ insulin 20 unit 20 minute

AGD Kalium post HD

Thank you