MORNING REPORT

18 June 2011
 Patient identity
Name : KS
Gender : Female
Age : 60 y.o
Address : Jl Segaramadu no.03
Kedonganan
Religion : Islam
Mariage : Married
Time arrived : 16.13 WITA
 ANAMNESA
Chief complaint : Vomiting out of blood
Present history :
Vomiting out of blood since 1 day BATH
(17/6/11, 0300)
Frequency 3-5x/day, volume 2 Aqua
glass/times
Crimson in colour
Consist of food leftover and Blood clot (+),
frothy (-)
Preceded by nausea and stomach discomfort
Currently dont have such compaint
 Epigastrial pain since 2 days BATH
Episodic pain with burning sensation
Gradual onset, getting worse with time
not radiate to other places
Not relieved with consumption of food
 Blackish stool since yesterday
morning (1 day BATH)
Frequency of 2 times, volume Aqua
glass/ times, blood (-)
Currently do not have such complaint
Urination: 3 4 x/day, yellowish, with
volume glass each urination.
Last urination at 15.30 WITA: yellowish,
volume ~ aqua glass

The complaint of fever, cough or SOB

were denied by the patient.
Past History

History of the same complaint was denied by the patient

History of excessive drinking, excessive urination, and

excessive food consumption were claimed by the patient
since 3 months ago, but she didnt checked for her blood
sugar level

History of Hypertension (+) since 3 months ago and not

routinely controlled to doctor nor medication

History of heart disease, diabetes mellitus were all

denied by the patient
Drug history
History of taking traditional medicine ( i.e. Jamu Mustika Dewa)
since 4 months ago because of feeling tired
History of Admitted to Kasih Ibu Hospital at 03.00 WITA ,
17/06/11; but she required to discharge herself at 15.00 WITA
17/06/11
Medication received from Kasih Ibu hospital as follows:
- Tranexamide Acid 3 x 500 mg
- Lansoprazole 1 x 30 mg
- Syrup form of medication (she forgot the name of the
medication)

Family history
None of his family member is having the similar complaint.

Social history
History of alcohol consumption and smoking was denied.
Phisical examination
General apearance: moderately ill
Conciousness: compos mentis
BP: 140/90 mmHg (supine position)
RR: 24x/min , regular
Pulse: 100x/min, reguler, adequate filling
Tax: 35,7 C
BW: 67kg
BH : 165cm
BMI: 24.6 kg/m2 ( pre-obesity )
Physical examination
Eyes : conjunctiva pale +/+, icterus -/-
ENT : papilla atrophy (-)
Neck : JVP +2 cm H2O, lymph enlargement (-),
Thorax :
Heart :
Insp : ictus cordis not visible
Palp : ictus cordis not palpable
Perc : UB: ICS II, RB: PSL D, LB: 2 cm lateral to
left MCL
Ausc : S1S2 single regular murmur (-)

Lungs :
Insp : symmetrical
Palp : tactile fremitus N/N
Perc : sonor/sonor
Ausc : Vesicular +/+; ronchi -/-; wheezing -/-
Phisical examination
Abdomen: I: distensi (-)
A: Bowel sound (+) normal
P: H/L not palpable
Epigastrial tenderness(+)
Ballotment (-)
P: tympani
Extremity: pitting edema (-), warm (+), petechie (-)
RT :
- Anus Sphincter Tone (+)
- Mucosa : Smooth (+), mass (-)
- Pain (-)
- blackish stool (-), fresh blood (-), mucus (-)
Laboratory Findings- Full blood count
Parameter Result Unit Reference
range
WBC 5.5 103/L 4,1 10,9
-Ne 2.5 45.8% 103/L 2,5 7,5
-Ly 1.6 28.1% 103/L 1,0 4,0
-Mo 0.7 13.0% (H) 103/L 0,1 1,2
-Eo 0,7 12.9% (H) 103/L 0,0 0,5
-Ba 0.0 0.2% 103/L 0,0 0,1
RBC 2,65 (L) 106/L 4,00 5,20

HGB 6.4 (L) g/dL 12,00 16,00

HCT 19,7 (L) % 36,0 46,0

MCV 74.6 (L) fL 80,0 100,0

MCH 24.3 (L) pg 26,0 34,0

MCHC 32.6 g/dL 31.0-36.0

RDW 18,0 (H) % 11.6-14.8

PLT 92 (L) 103/L 40 440

 Blood Chemistry

Parameter Result Unit Reference Interpretation

range
SGOT 41.9 U/dL 11,00-33,00 H

SGPT 32.2 U/dL 11,00-50,00 N

BUN 19,00 mg/dl 10,00-23,00 N

Creatinine 0,69 mg/dl 0,50-1,20 N

RBG 314 Mg/dL 70,00-140,00 H

Amylase 36.0 U/dL 25,00-120,00 N

GFR : 91,7 ml/min

Osmolarity : 294,23 mOsm/L
Blood Gas Analysis
Value Remarks Normal Range

pH 7.51 H 7.35-7.45
pCO2 36,00 35-45 mmHg
pO2 92,00 80-100 mmHg
HCT 19,00 L 37-48%
HCO3- 28,7 H 22-26 mmol/L
TCO2 29,8 24-30 mmol/L
BE(B) 5,2 H -2 +2 mmol/L

Natrium 135 L 136-145 mmol/L

Kalium 2,8 L 3.5-5.1 mmol/L

Conclusion : Metabolic alkalosis

Thorax AP ( 18/06/2011)

Cor: CTR 60 %
Pulmo: bronchovascular
pattern normal
infiltrat (-)
nodul (-)
Sinus costophrenicus:
sharp
Diaphragma with normal
limit

Conclusion: Heart and

Lung within normal
limit
ECG

Sinus rhythm, HR 95x/mnt, reguler,

Axis normal, PR interval normal, QRS complex N
ST-change (-), T wave N
Conclusion: Normal
 Working diagnosis

- Obs. Hematemesis cb. Susp. Peptic ulcer

- Moderate hypochromic-microcytic anemia cb.
Iron defeciency anemia dd chronic disease
- Hypokalemia cb. Susp. Loss dd. Shift
- Metabolic Alkalosis
- Thrombocytopenia cb. Susp. drug
- Hyponatremia Normoosmolar Euvolemia
Asymptomatic

- DM type II
- Hypertension Stadium I
THERAPY
Hospitalised
O2 4L/minute
Fasting 1 x 24 hours
NGT insertion blood clot (+) , crimson in colour
Drip KCL 25 Meq in NaCL 0,9% 20 drops/mnt
Drip Insulin 4 IU in NaCl 0,9% until BS 250 2 IU in
NaCl 0,9% until BS 200 1 IU in D5% until BS 140-180
Omeprazole 1 x 80 mg 2 x 40 mg
Antacid Syr 3 x CI
Sucralfat syr 3 x CI
Tranexamate Acid 3 x 500 mg
PRC transfusion till Hb > 10 mg/dl
Captopril 3 x 25 mg tab (withhold)
 Diagnostic planning
Serum iron, TIBC, ferritin
Blood smear
EGD
BS 2 hours PP
HbA1c
Lipid Profile
UL
FOBT
Consult opthalmology

Monitoring
Vital signs
Complaints
Water balance
CBC post transfusion
Monitoring BSL @ hour until BS 140-180 BS @ 6 hour
Na-K level @ 4 hour
Thank you