Morning Report

December 1th, 2015

Doctor in Charge : Dr. dr. Agus Yuwono Sp.PD-KEMD

Patients Identity
Name
:
Sex
:
Age
:
Weight
:
Occupation
:
Hospitalised since

Mr. A
Male
52 yo
70 kg
employee
: December 1 th, 2015

Summary of Data Base

Mr. Ruwansyah / 48 yo / Male (autoanamnesis)
Chief Complaint : blood vomiting
The patient suffeed blood vomiting since five hour ago before he hospitalised.
Vomit six times, and the contains of vomit is blood, as much 150 cc every
vomit. There is a bit of blood clot every vomit. The patients complaint melena
from five hour ago. Melena two times, normal consistency, the colour of the
feces is black, no slime. After that, the patient sometimes feel dizziness and
weakness.
Patients also complained of the right upper stomach, intermittent pain. For the
pain scale is 5-6.

 History of prior illness : DM (-)

HT (-)
History of familial illness: DM (-) HT (+)

Physical Examination
General appearance

Looked mildly ill Conscious, GCS : 4 5 6

Blood Pressure

100/80 mmHg

Pulse Rate
Respiration rate
T ax

84 bpm regular, strong

24 tpm
36,10C

Head

Pale conjunctiva (+/+), Jaundice sclera (+/+)

Neck

JVP R + 4 cmH2O at 30

Chest Heart

Ictus invisible, palpable in MCL (S) ICS VI

RHMSL (D), LHMIctus
S1 S2 single, murmur (-) gallop (-)

Lung

position

Simetric VF D=S , Vesiculer BS,

Rh - -

Wh - -

Abdomen

Flat, soft, BS (+6) N, Timpanic, hepatomegaly (+)

Pressure pain (+) right hipokondriaca region

Extremities

D & S : Edema of legs (+/+), pitting edema (+)

S/S

Laboratory Result
Items

Result

Normal Value

Unit

Hemoglobine

5.9

14.00 - 18.00

g/dl

Leukocyte

13.1

4.0 10.5

thousand/ul

Eritrocyte

2.14

4.50 6.00

million/ul

Hematocrit

19.2

42.00 52.00

Vol%

Trombocyte

173

150 450

Ribu/ul

RDW-CV

17.9

11.5 14.7

MCV

74.1

75.0 96.0

Fl

MCH

27.5

28.0 32.0

Pg

MCHC

30.1

32.0 38.0

Hematology (30-11-2015)

Items

Result

Normal Value

Unit

Random blood glucose

151

<200

mg/dl

SGOT

130

0 - 46

U/l

SGPT

71

0 - 46

U/l

Ureum

226

10,0 50,0

mg/dL

Creatinine

2.1

0,7 1,4

mg/dL

Result

Normal Value

Unit

Natrium

136

135-146

mmol/l

Kalium

2.8

3.4 5.4

mmol/l

122.2

95-100

mmol/l

Items

Chlorida

CUE AND CLUE

PL

IDx

Male/57 yo
1.

Hematem
esis
Melena

1.1 Varices
Esophagus
1.2 Peptic ulcer
1.3 Gastritis
erosif

2.

Anemia
HN

2.1 acute blood

because 1
2.2 ADB

Anamnesis
-bloody vomit
-melena
-Pain in the upper right
stomach
Physical Examination
Blood preasure :
100/80
Abdomen:
hepatomegaly (+)
Pain (+) right
hipocondriaca
Ekstremitas inferior:
Edema (+/+), pitting
edema (+/+)
Laboratory:
Hb: 5.9
Leukocyte: 13.9
Eritrocyte: 2.14
Hematocrite: 19.4
MCV: 74.1
MCH: 27,5
SGOT: 130
SGPT: 71
Ureum:226
Creatinine: 2.1

PDx

PTx

DLO
SGOTSGPT
Albumin
PT /APTT
Seromarker
hepatitis
USG
abdomen
OMD

IVFD NS 20tpm
Inj Omeprazole 2x1
Inj Asam Tranexamat 3x1
Inj Vit K 3x1
PO: Sucralfat 3xI C

DLO

Pro Tranfusion PRC until

Hb >10

PMo
VT
BR

Thank you