JANUARY 23 th 2014

CC : Black stool since 1 day ago

Present illness history:

Black stool since 1 day ago, watery consistency, frequency 4 x / day Black vomite since 1 day ago, frequency 15 x/day Enlargment stomach since 1 months ago, longer big progressively. Fatigue since 1 months ago Dizzines since 1 weeks ago Patient ever hospitalization in M.Jamil Hospital with chief complain black vomite and black stool . urinate usual

Consc : fully alert BP : 90 /60 mmHg HR : 89 x/ RR : 21 x/ T : 36,8 0 C Eye : Conjuctiva anemic (+/+),sclera icterus (-) Neck : JVP 5-2 mmHg Lung : vesiculer, rales (-/-), Whezzing (-/-) Heart : Ictus was palpable 1 finger medial of LMCS RIC V, cardiomegaly (-) Abdomen: enlargment, Liver palpable 2 finger, 2 Bpx, chewy, blunt edge,nodul surface, tenderness (-) and spleen S2 Ext : Fisiology reflex :(+)/(+) Normal Pathology reflex:(-)/(-) Normal Edem (-)/(-)

Hb : 3,4 gr/dl Leu : 7600/mm3 Ht : 32 % Platelets : 96.000 /mm3 APTT : 91,2 PT : 24,6 MCH/MCV/MCHC : 21,7/67/32,3

WD/:
Hipovolemic shock cb Hematemesis melena Cb Rupture varices esofagus cb Hepatic cirrhosis post necrotic decompensata stage Hematemesis melena Cb Rupture varices esofagus cb Hepatic cirrhosis post necrotic decompensata stage Severe Anemic normocitic normochrom cb Acute bleeding

 Rest/

Flow NGT, Fasting maximal 3 days Loading NaCl 0,9 % until Sytolic Blood presure > 100 mmHg or urine out put 0,5-1 cc/KgBW/hour Bolus Sandostatin 1 amp, continue drip 2 amp in 500 cc 8 hours/kolf Inj. Vit K 3 x 1 amp (iv) Ciprofloxacin 2 x 500 mg Lactulac syr. 3 x cth 2 Curcuma 3 x tab Transfution PRC until Hb > 8 gr/dL, Crossmatch Fluid balance Apply Catheter Clisma 2x/day

Lung X-ray Abdomen USG Gastroscopy

CC : Diarrhea since 3 months ago

Present illness history:

Diarrhea since 3 months ago, watery consistency, slem (+), frequency 2-3 x / day, blood (-) Cough since 3 months ago, white sputum, blood (-) Fever since 2,5 months ago especialy every night, no high, no shivering and sweat (+) History of night sweat since 2,5 months ago Decreased appetite since 3 months ago Pale since 1 months ago Sprue (+) since 1 months ago Breathlessness (-) Ulcer at regio right axilla and both of inguinal since 4 yeras ago, intermittent Both of legs swollen since 1 months ago urinate usual

Consc : fully alert BP : 100 /80 mmHg RR : 20 x/

HR T

: 96 x/ : 36,5 0 C

Eye : Conjuctiva anemic (+/+),sclera icterus (-) Neck : JVP 5-2 cmH2o Lung : Bronchovesiculer, rales (+/+) apex both of lung Whezzing (-/-) Heart : Ictus was palpable 1 finger medial of LMCS RIC V, cardiomegaly (-) Abdomen: Liver and spleen unpalpable Ext : right Axilla : ulcus (+), size 2x1x1 cm, pus (+) Inguinal Bilateral : each 1 ulcus , size 3x 1x1 cm, Pus (+) Legs : oedema +/+, RF +/+, RP -/-

Hb : 7,5 gr/dl Leu : 14.600/mm3 Ht : 32 % Platelets : 228.000 /mm3 MCH/MCV/MCHC : 20,9/66/31,5 Albumin/ Globulin : 1,2/3,6 gr/dL

WD/:
Chronic diarrhea cb Colitis of TB Lung TB with skrofuroderma Hematemesis melena Cb Rupture varices esofagus cb Hepatic cirrhosis post necrotic decompensata stage Moderate Anemic micrositic hipochrom cb Chronic disease Hipoalbuminemia Cb Low intake cb chronic disease

 Limfadenitis

TB Moderate Anemic micrositic hipochrom cb deficiency Iron

 Rest/

low fiber diet high calory high protein IVFD NaCl 0,9 % 12 hours/kolf Inj. Ceftriaxon 1 x 2 gr (ST) PCT 3 x 500 mg Ambroxol syr. 3 x cth 2 Correction Albumin 20 % 100 cc fls 1 Fluid balance

Exp. Lung X-ray FAB sputum I,II,III FAB feces I,II,III Cultur pus

CC : Breathlessness since 8 hours ago

Present illness history:

Breathlessness since 8 hours ago, influence activity, no influenced by weather and foods Nausea since 1 weeks ago and no vomite Waist pain since 1 weeks ago, intermitten, pain like jab Both of legs swollen since 3 days ago History of legs swollen (+) History of sand urinate (-) Defication usual History of DM since 17 years ago, uncontrolled History of Hipertention since 17 years ago

Consc : fully alert BP : 150/80 mmHg RR : 31 x/ Eye Neck Lung Heart

HR T

: 105 x/ : 37,4 0 C

: Conjuctiva anemic (+/+),sclera icterus (-) : JVP 5+2 cmH2o : Bronchovesiculer, rales (+/+) Whezzing (-/-) : Ictus was palpable 1 finger lateral of LMCS RIC VI,

Abdomen: Liver and spleen unpalpable Ext : right Axilla : ulcus (+), size 2x1x1 cm, pus (+) Inguinal Bilateral : each 1 ulcus , size 3x 1x1 cm, Pus (+) Legs : oedema +/+, RF +/+, RP -/-

Hb : 7,5 gr/dl Leu : 14.600/mm3 Ht : 32 % Platelets : 228.000 /mm3 MCH/MCV/MCHC : 20,9/66/31,5 Albumin/ Globulin : 1,2/3,6 gr/dL

WD/:
Chronic diarrhea cb Colitis of TB Lung TB with skrofuroderma Hematemesis melena Cb Rupture varices esofagus cb Hepatic cirrhosis post necrotic decompensata stage Moderate Anemic micrositic hipochrom cb Chronic disease Hipoalbuminemia Cb Low intake cb chronic disease

 Rest/

low fiber diet high calory high protein IVFD NaCl 0,9 % 12 hours/kolf Inj. Ceftriaxon 1 x 2 gr (ST) PCT 3 x 500 mg Ambroxol syr. 3 x cth 2 Correction Albumin 20 % 100 cc fls 1 Fluid balance

Exp. Lung X-ray FAB sputum I,II,III FAB feces I,II,III Cultur pus