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PD
Prior to the vomiting, she felt nausea. She also complained about
blacktarry solid stool since 2 days ago, 1 time a day. She did not complain about abdominal pain but she he had decreased of appetite. She also suffered from headache after the first time she vomited, accompanied by general weakness.She went to general practitioner and she had given 2 types of medicines. The doctor
asked her to go to hospital but she didnt go. After she vomited
again on the next day, her family took her to RSSA.
Patient also seldomly suffered from low back pain since some years ago. Medicine consumed (painkiller).
Physical examination
BP = 110/60mmHg Head Neck Thorax: Cor: PR = 96 bpm irreguler Anemic + JVP R + 0 cm H2O Ictus invisible and palpable MCL ICS V Sinistra 1 cm lateral RHM SL Dextra LHM ictus S1 S2 single, murmur Lung: Symmetric SF D=S SS SS SS VV VV VV Rh - - - Wh - - - RR = 20tpm GCS 456 Icteric Inserted NGT : bloody + Tax = 37.0 C General appearance looked moderately ill
Abdomen Extermities RT
Flat, Soefle,, liver span 8cm, troube space thympani, shifting dullness -, BS + Warm, edema -, pale extrimity + Sphincter ani no abnormality, , Melena -
Laboratory findings
Lab
Leukocyte
Value
14 700 3.500-10.000/L
Lab
Natrium Kalium
Chlorida
Value
134 4.12
116
Haemoglobine
3.6
11,0-16,5 g/dl
MCV
MCH RBC
PCV Trombocyte
65
19.9 1.78x106
11.6 359 000 35-50% 150.000390.000/L
albumin
RBS PPT aPTT SGOT SGPT
3.08
153 12.4 23.7 16 11
3.5-5.5
K:11.9 K:27.3
11-41 U/L 10-41U/L
Ureum Creatinine
72.1 0.76
UL: eritrocyte
2+
ECG 1/4/2012
Sinus rhytm, heart rate 97 bpm Frontal Axis : Normal Horisontal Axis : normal PR interval : 0.12'' QRS complex : 0.08 QT interval : 0.36 Conclusion : sinus rhytm, heart rate 97 bpm
CXR 1/4/2012)
Thorax AP position, asymetric, less inspiration, KV is not enough Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are blunt Right hemidiaphragma and left hemidiaphragm are dome shape Lung : Cor site and shape are normal, CTR: 60% Conclusion: cardiomegaly
Lumbasacral AP/Lateral position Soft tissue normal Bone: disalignment Intestine: Air (+) feces (+)
Conclusion: Scoliosis Lumbalis
Female/85 yo Vomit of coffee ground appearance, volume: more than a glass Blacktarry stool Headache Took painkiller for back pain (unknown) PE: Anemic conjunctiva NGT : hematemesis Extrimity: pale RT: melena -
1.Hemate mesismelena
Endoscopy
Fasting NGTGastric lavage/8 hours1 times negative/cleanstart liquid diet 6x200cc (1cc=1kcal) IVFD NaCl 0,9% 30-40 dpm Omeprazole 1x40 mg iv Inj metoclopramid 3x10mg
Female/85 yo Ax: General weakness,pale PE: Anemic conjunctiva+ Pale in all extrimities Hb 3.6 MCV= 65 MCH=19.9 RBC=1.78x106
Female/85 yo Felt pain on her back (seldom) Took painkiller (unknown) Photo Lumbosacral AP/Lateral- scoliosis lumbal
4. Azotemia