MORNING REPORT

COASS INCHARGE


Geo Bertha Fernanda
Mutiara Nurmasari Azizah


Moderator : dr Sri Sunarti Sp.PD
Summary of Data Base
Mr. A / Male/ 52 y.o//w. 25
Chief complain: bloody vomiting
Patient suffered from bloody vomiting since 2 days before admission. It
occurred one time after the patient drunk alcohol. Bloody vomiting was began
with red blood, volume 500 cc / 2 glass. Actually, this is the first time, he
suffered from bloody vomiting.
Patient also suffered from black tarry stool since 2 days ago. It
occurred 2 times, each volume about 1/4 glass (50cc) with liquid consistancy
but without fever or abdominal pain.
Patient also suffered nausea. He also felt decrease of appetite and
only ate soft diet like porridge 3-4 spoon per day.
Patient also felt general weakness and he went to the General
Phychysian. The General Phycysian suggest him went to the hospital.



History of past illness:
Patient had history of black tarry stool one month ago before admission.
He had history of tiphoid fever about 10 years ago, and admitted in the
RSSA for 10 days.
History of epigastric pain (-), history of consumed NSAID or potion (-)
Family history : There is no family member complaining the same with
him.
Social history : He is married. He is a caf singer. Patient is alcoholik and
drank alcohol 1-3 times per month since 30 years ago. Patient had smoking
2-3 bars/day since 20 years old. History of multiple sexual partner.

Physical examination
BP = 120/70 mmHg PR = 98 bpm,
weak, regular
RR = 22 tpm Tax : 37,2C
General appearance looked moderately ill GCS 456
Head Pale conjunctiva (+) Icteric sclera (-)
Neck JVP R + 0 cmH
2
O 30 degree
Chest Heart: Ictus invisible and palpable at MCL S, ICS V Sinistra
LHM ictus, RHM SL D
S1, S2 single, murmur ( -)
Lung: Symetric, SF D=S s s v v Rh - - Wh - -
s s v v - - - -
s s v v - - - -
Abdomen

Soefl, liver span 6 cm, troube space tympani , bowel sound (+)
normal

Extremities Warm acral (+), edema (-)

Rectal touche Melena (-), tonus spingter ani (+)
Lab Value (Normal) Lab Value (Normal)
Leukocyte 13.930
3.500-10.000/L
Natrium 132 136-145 mmol/L
Haemoglobine 6,60 11,0-16,5 g/dl Kalium 3,42 3,5-5,0 mmol/L
PCV 20,50 35-50% Chlorida 114 98-106 mmol/L
Trombocyte 43.000 150.000-
390.000/L
RBS
Trigliserida
103
212
<200 mg/dl
(0-200)
MCV
MCH
85,10
27,40
80-96 fl
26,5-33,5 pg
Bilirubin total
Bil. Direct
Bil. Indirect
0,75
0,47
0,28
0,00- 1,10
0,00-0,25
0,00-0,50
SGOT 58 11-41U/L Ureum 41,00

10-50 mg/dL
SGPT 56 10-41U/L Creatinine 0,89 0,7-1,5 mg/dL
PPT 11,70 K. 11
APTT 27,60 K. 25,3







Lab Value Lab Value
Urinalysis
10 x
SG
1.015 Epithelia 1
PH
6 Cylinder -
Leucocyte
- Hyaline -
Nitrite
- Granular -
Protein
- Leukocyte -
Glucose
- Erythrocyte -
Erythrocyte
-
40 x
Eritrosit
0-1 /hpf
Keton urine - Leukocyte 3-4 /hpf
Urobilinogen - Crystal -
Bilirubin - Bacteria -
CUE AND CLUE PL IDx PDx PTx PMo
Male/50 yo
Ax:
-Bloody vomiting
-Nausea
-history alcohol user
-black tarry stool
-PE:
Bp :120/70 mmhg,
HR :88 bpm ,
RR:22 tpm
-pale conjungtiva (+)
-NGT: coffe ground (+)
Lab:
Hb 6,6 g/dl
PCV 20,50
MCV 85
MCH 27,4
SGOT : 58
SGPT :56
total Bilirubin 0,75
Bil Direct 0,47
Bil Indir 0,28
1. Haematem
esis dan
Melena
1.1Ciirosis
hepatis
1.1.1 Varices
Esophagus

1.2 PUD
1.2.1.peptic
ulcer
1.2.2.duodenal
ulcer
Endoscopy

-Fasting
-NGTgastric lavage/8
h, if 3x clear start
fluid diet 6x200 cc
-line I:
IVFD NS 0,9% 20 dpm
-line II:
Drip Octreotide 50
mcg/h
-line III:
Drip Lansoprazole
6mg/h
(insert 2 vial
Lansoprazole in 500cc
NS 20 dpm)
-inj. Metoclopramide
3x10 mg (IV)
-PO: Lactulosa syr 3 x2
cth
Subj,
Vital
sign,
CUE AND CLUE PL IDx PDx PTx PMo
Male/50 yo
Ax:
-Bloody vomiting
-Nausea
-history alcohol user
-black tarry stool
-PE:
Bp :120/70,
HR :bpm ,
RR:22 tpm
-pale conjungtiva (+)
-NGT: coffe ground (+)
Lab:
Hb 6,6 g/dl
PCV 20,50
MCV 85
MCH 27,4
SGOT : 58
SGPT :56
total Bilirubin 0,75
Bil Direct 0,47
Bil Indir 0,28
Albumin ?
Globulin ?
2. Cirrhosis
hepatis
2.1 post
necrotic
hepatitis B/C
infection

2.2 alcoholic
liver disease
HbsAg
Anti HCV
USG
Abdomen
Propanolol 2x10mg
(postponed)

Spironolactone
0-100mg-0
(postponed)
vs
Male/52yo
Ax:
-Bloody vomiting
- black tarry stool
PE:
-pale conjungtiva
(+)
Lab:
Hb 6,6 g/dl
PCV 20,50
MCV 85
MCH 27,4

2. Anemia
NN
2.1.dt PLno 1 Blood
smear,

reticulocy-
te count
Tranfusion PRC 1
pack/day until HB
>8
VS,
cbc
Male/70 yo
Ax:
PE:
Lab:
Trombocyte
43.000
3
Trombocytop
enia
3.1
Haematologic
al Disorder

3.2 dt Liver
cirrosis
(hypersplenis
m)
blood
smear
Ptx Platelet
consentrat
tranfusion
(postponed)
Vs,
cbc
CUE AND CLUE PL IDx PDx PTx PMo
Thank you