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IDENTITY

Name Gender Age Nationality Religion

Occupation
Address Marital status

TA

: SY : Male : 33 years old : Indonesia : Islam : Employee :Jl. Gang Lebah No. II Denpasar : married :22 August 2012 (14.00 p.m)

ANAMNESIS
Chief Complain: Vomiting Present 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 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 cant 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 History
Patient never felt the same complain like this before. History of allergic, Heart ds, Asthma, Lung TB were

denied.

Family History
History of heart ds, Asthma, Lung TB, in family

member were denied Social History He drank alcohol 3 days BATH with his friend, but patient forget the brand.

Physical examination

General appearance Level of consciousness VAS BP HR RR Temp. Ax Height BW BMI

: moderately ill : Somnolen (E4V4M5) : 0/10 : 110/70 mmHg : 100 bpm : 22 bpm : 36,5 0C : 170 cm : 65 kg : 22, 49 kg/m2

Eyes

Conjuntival pallor -/-

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


ENT

Ear: secret (-). Nose: secret (-), hyperemia (-) Throat: pharing hyperemia (-), T1/T1. Tenderness (+) JVP 0 cmH2O Gland enlargement (-)
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 Pa Pe Aus : Simetrically (static & dinamic) : Vocal fremitus N/ N : Sonor/ Sonor : Vesicular +/+, Rhonki-/+, Wheezing -/-

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

EXTREMITIES
Warm (+), oedema (-)

Parameter

Pemeriksaan penunjang
Resul t Unit Remarks Paramater

Result

Unit

Remar ks

WBC
NEUT LYMPH

16,68 103L
89,60 % 103L 7,10 % 103L

Hematokrit
Platelet MCV MCH

53,90 %
511 103L 85,50 fL 28,60 pg

MONO
EOS BASO RBC Hemoglobin

2,60 % 103L
0,10 % 103L 0,10 % 103L 6,05 106L 18,00 g/dL

Chemical COUNT
Parameter BUN Creatinin SGOT SGPT RBG Cloride Result 25,00 1,34 30,00 88,00 110,00 95,22

PH
PCO2 P02 HCO3 BE SO2 NA K

7,1
10 165 3,20 -26,30 99 131 7,3

Chest X-Ray

Cor: 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

Assessment
Intoxication methanol
Acidosis metabolic Hipercalemia

Toxic optic neuropathy

PLANNING
Theraphy
HD Cito IVFD Nacl 0,9% 20 tpm Thiamin inj

Monitor
AGD Kalium post HD

Ca Glukonas 3x1 amp


Nebulizer salbutamol 20

mg D 40% 100 cc+ D 10 % 100 cc+ insulin 20 unit 20 minute

Thank you