MORNING CASE REPORT

12TH JUNE 2011

IDENTITY

Name : SH
Age : 55 y.o
Gender : female
Ethnicity : Javanese
Religion : Muslim
Address : Br. Tinggal Sari Tabanan.
MR No. : 01.48.74.26
Time of admission : 12 June 2011, 13.15 PM

ANAMNESIS
CC: bloody vomiting
Present history:
The patient complained of vomiting 4 days BATH and bloody
vomiting since 3 days BATH. The bloody vomiting is said to be
black in color, mixed with food that eaten, frequency 2 times,
volume 1 glass of aqua.
The patient also complaint gnawing pain on upper abdomen since
2 weeks ago. Pain occurs shortly after eating and persist even she
vomiting. The pain radiated posteriorly or spread to all region of
stomach. Patient sometimes feel discomfort on her stomach.
Cough (-), shortness of breath (-)
Decrease of appetite for the past 2 months, at that time she often
feels pain on her stomach however it didnt follow by vomitting
yet.

Black and hard stool (+) 1x/day 3

day BATH.
Urination was normal 3 4x/day,
blood (-)

Past History:
Patient also complaining vomiting since 8
years ago, volume 100 cc.
7 times treated in hospital because of
vomiting.
Have medication diagnose with Gastritis.

Family History:
Her mother has same complain (bloody
vomiting)
Social and Daily habits:
Eat irregularly (+)
Smoking (-), alcohol (-)

Physical Examination

General appearance
: moderate
Level of consciousness/GCS
: CM:
E4V5M6
Vital Sign:
BP:
RR:
PR:
t
ax :

100/ 60 mmHg
26 x/min
100 x/min
36,7C

Eyes : Anemis (+/+); icterus (-/-); pupillary reaction +/

+
ENT : tonsils T1/T1; pharyngeal hyperemia (-); tongue
normal;
lip cyanosis (-)
Neck : JVP RP + 2 cmH2O; lymph node enlargement (-).
Thorax :
Heart :
Insp
Palp
Perc
Ausc
Lungs :
Insp
Palp
Perc
Ausc

Symmetric
:
:
:
:

ictus cordis not visible

ictus cordis not palpable
UB: ICS II, RB: PSL D, LB: MCL S
S1S2 single regular murmur (-)

:
:
:
:

symmetrical
tactile fremitus N/N
sonor/sonor
vesicular +/+; ronchi -/-,whez -/-

Abdomen

Insp
Ausc
Perc
Pal

:
:
:
:

distention (-), colateral(-), caput medusae (-)

bowel sounds (+) increase.
Tympani
Tenderness (+)
Hepar : non-palpable
lien : non-palpable

Extremities : warm +/+; eritema palm -/+/+

-/-

Laboratory Examinations

FULL BLOOD COUNT

Parameter

Result

Unit

Remark

Reference range

WBC

8,5

103/L

4,1 10,9

-Ne

14,2 (82,1%)

103/L

2,5 7,5

-Ly

1,7 (9,9%)

103/L

1,0 4,0

-Mo

1,2 (7,0%)

103/L

0,1 1,2

-Eo

0,1 (0,7%)

103/L

0,0 0,5

-Ba

0,1 (0,3%)

103/L

0,0 0,1

RBC

2,7

106/L

4,00 5,20

HGB

8,4

g/dL

12,00 16,00

HCT

24,4

36,0 46,0

MCV

90,4

fL

80,0 100,0

MCH

31

pg

26,0 34,0

MCHC

34,3

g/dL

31,0 36,0

PARAMETER
PT

RESULT
12

INR
KONTROL PT
APTT

1,1
12,4
33,0

Normal.
perbedaan kontrol
< 2 detik
0,9 1,1
Normal.
Perbedaan kontrol
< 7 detik

KONTROL APTT 34,6

PARAMETER

HASIL

SATUAN

RUJUKAN

Blooding Time

100

Menit

1,00-3,00

Cloting time

730

menit

5,00-15,00

clinical chemistry
Parameter

Result

Unit

Remarks

Normal Range

SGOT

12,3

IU/L

11,00-33,00

SGPT

7,9

IU/L

11,00-50,00

BUN

35,480

Mg/dl

8,00-23,00

Creatinin

0,6

Mg/dl

0,70-1,20

Random Blood Glucose

108

Mg/dl

70,00-140,00

Bilirubin total

0,33

Mg/dl

0,00-1,30

Bilirubin Indirect

0,24

Mg/dl

-----

Bilirubin direct

0,09

Mg/dl

0,00 -0,30

Alkali phospatase

53,97

Mg/dl

53,00 128,00

Total Protein

5,92

Mg/dl

6,40 8,30

Albumin

3,309

Mg/dl

3,40 -4,80

Globulin

2,615

Mg/dl

----

Blood gas analysis

Parameter

Result

Unit

Remarks

Reference
range

7.580

Tinggi

7,35 7,45

pCO2

37,

mmHg

Rendah

35,00 45,00

pO2

130

mmHg

Rendah

80,00 100,00

Hct

26

Rendah

37,00 48,00

HCO3-

34,7

mmol/L

22,00 26,00

TCO2

35,8

mmol/L

24,00 30,00

BE(B)

11,9

mmol/L

-2 2

SO2c

95,2

--

THbc

8,10

g/dL

Na

135

mmol/L

135,00
145,00

2,8

mmol/L

3,40 4,80

pH

Rendah

13,00 18,00

ECG Result

Sinus Rhythm
HR 111 x/minute
Axis Normal
Sinus (+)
PR Interval Normal
P wave Normal
ST changes (-)

Chest X-Ray

Cor: CTR 51%

Pulmo: nodul(-),
infiltrat (-),
broncovaskular
pattern normal
Left and right sinus
pleura are sharp
Left and right
diafragma is normal
Conclusion: Normal

Assessment
- Obs. Hematemesis ec susp. Peptic ulcer
Dd/ gastritis erosive
- Anemia.

Planning Therapy

Hospitalized
IVFD NaCl 0,9% 20 dpm
Puasa
NGT+GC blood clot (+) blood (-)
Antacid syr 3xC1
Sucralfat syr 3xCI
Pantoprazole 80 mg 2x40 mg (iv)
Omeprazole 2x20mg (p.o)
Tranfusion PRC until HGB > 10g/dl

Planning Diagnostic

Antigen fecal, serology for H pylori

If H Pylori (+) eradikasi H Pylori
Endoscopy.

Monitoring
Vital signs/complaint
Sign of bleeding

THANK YOU