Duty report

march 20th, 2017

Erwaty latif, female, 74 yo, FW 17

Chief complain
Black stool since 3 day ago
 Present illness history
◦ Black stool since 3 days ago. Frequency 2-3 times per
day.
◦ Bloody vomit (-)
◦ Naussea and epigastric pain (-)
◦ Dizziness since 3 days ago.
◦ Fatique since 3 days ago
◦ Paleness since 3 days ago.
◦ Fever (-)
◦ Breathlessness (-)
◦ History of bleeding (-)
◦ History using pain killer for headache since 3 years
(+)
◦ Patien had been history hospitalized 3 months ago for
2 times with same symptom and get transfussion
22/02/2018
Physical Examination
 level of consciousness : CMC

 BP : 140 / 80 mmHg

 HR : 78 x/minute

 RR : 21 x/minute

 T: 37oC
 Eye
◦ Conjunctiva are anemis +/+
◦ Sclera icteric -/-

 Neck
◦ JVP 5 - 2cmH20

 Lung:
◦ Inspection: simetric left = right
◦ Palpation: fremitus left = right
◦ Percussion: sonor
◦ Auscultation: vesicular, Rh -/-, Wh -/-

 Cor:
◦ Inspection: ictus is not seen.
◦ Palpation: ictus is palpated at 1 finger medial LMCS RIC V
◦ Percussion:
 Left border: 1 finger medial LMCS RIC V
 Right border: linea sternalis dextra
 Upper border: RIC II
◦ Auscultation: Pure rhythm, murmur (-)
 Abdomen:
◦Inspection: Enlargement (-)
◦Palpation: liver and spleen not palpable
◦Percussion: tympani
◦Auscultation: bowel sound (+) normal

 Extremities:
◦Physiologic Reflex +/+
◦Pathologic Reflex -/-
◦Oedema -/-
Laboratory
Examination Result
Hb 6,8
Leukosit 4200
Trombosit 195.000
Hematokrit 21
Pt/aptt 12,1/40,8

Na / K / Cl 134/3,8/108
Ur / cr 41/1,2
RBG 103

22/02/2018
Working Diagnose
 Melena cb gastropathy NSAID
 Moderate anemia normocytic
normochrom cb acute bleeding
 Hypertension stage I cb essensial
Therapy
 rest / flow NGT, fasting 8 hours  gaster diet I low salt II
 Bolus prosogan 2,5 amp continued with drip prosogan 2,5 amp in
500 cc Nacl 0,9 % in 8 hours
 Sukralfat syr 3x cth II
 Amlodipin 1x 5 mg
 Crossmatch and transfussion PRC 1 unit/day
planning
 BMP

22/02/2018