Beruflich Dokumente
Kultur Dokumente
Cc:
Black stool since 2 weeks ago.
BP : 120/70 mmHg
HR : 94x/minute
RR : 20 x/minute
T: 36,5 C
Eye
Conjunctiva are anemic +/+
Sclera are icteric -/-
Neck
JVP 5-2 cmH20
Lung:
Inspection: simetric at statis and dinamic
Palpation: left = right fremitus
Percussion: sonor
Auscultation: vesicular, rales -/-, wheezing -/-
Cor:
Inspection: ictus not seen
Palpation: ictus is palpated at 1 finger medial LMCS RIC V
Percussion:
Left border: 1 finger medial LMCS ICS V
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: pure rhythm, no murmur
Abdomen:
Inspection: enlargement (-)
Palpation: liver palpabl and spleen no palpable,
epigastric tenderness (+)
Percussion: tympani
Auscultation: bowel sound (+)
Extremities:
Oedem -/-
Physiologic reflex +/+
Patologic reflex -/-
Laboratory
Hb 4,8 gr/dl
Ht 20%
WBC 6.680/mm3
Platelet 447.000/mm3
MCV/MCH/MCHC 51/12/24
Ur/Cr 14/1,1
Na/K/Cl/Ca 139/4,5/109/8,5
RBG 96 mg/dl
PT/aPTT 11,4/41,0
Working Diagnosis
Melena cb Peptic ulcer
Severe anemia microcytic hypochrome cb
chronic bleeding
Dd/
Melena ec Gastropathy erosiva
Severe anemia microcytic hypochrome cb
chronic disease
Therapy
Rest/ NGT flow fasting 8 h Gastric diet I
Bolus lansoprazole 60mg (IV)
Drip lansoprazole 60mg in 500cc NacL 0,9% finished
10 hours
Domperidon tab 3x10 mg (po)
Sucralfat syr 3xcth II (po)
Planning
Esophagogastroduodenoscopy