Morning Report

May 4th 2015

IDENTITY
Name : IMA
DOB : 1 May 1968
Age : 47 years old
Sex : Male
Religion : Hindu
Occupation : Seller
Nationality : Indonesian/Bali
Address : Banjar Samsam
Kerambitan
TOA : 29 April 2015
ANAMNESIS

Chief Complaint : Vomit with blood

- Patient was came to Tabanan Hospital with chief
complaint vomitting with fresh blood. He started to vomit
since the night BATH, vomitted 5 times and approximately
60ml in accumulation. He did not feel pain in epigastrium
or pain after/before eating before. He also did not
defecate fresh blood or blackish feces. Before he
vommited he was eating many things at banjar that he
cant remembered. Then at night he woken up and
vomitted blood. He was took to hospital immediately.
ANAMNESIS
History of Past Illness
He was having history of diabetes since two years
ago and very rarely get his disease controlled. He
had history about drinks, eat and urinate a lots
and decreasing in body weight approximately
15kg two years ago. He was on therapy of
glibencamid but never took his drugs regularly
and choose alternative medicine.

He dont have history of gastritis and any other

chronic disease.
ANAMNESIS
Family History
His family dont have history of chronic disease like
DM, HT, Kidney disease or others.

Personal and Social History

- Have stall that sells food, drinks and house
equipment.
- Never Exercise
- Never choose his food well, like porks, fats, sweet
drinks and soda.
Physical examination

General condition : moderately ill

Level of conciousness: compos mentis
GCS : E4V5M6
BP : 150/90 mmHg
T axila : 36,50 C
PR : 100 bpm, reguler
RR : 20 tpm, reguler
BW : 60 kg
BH : 161 cm
BMI : 23,14 kg/m2
Physical examination

Eye : pale conjunctiva (-/-), icteric sclera (-/-)

ENT : bleeding (-/-), hyperemia pharynx (-) Tonsil T1/T1
Neck : LN enlargement (-), JVP PR 0 cmH2o
Thorax : simetris
Cor Insp: ictus cordis unseen
Palp: ictus cordis palpable, ICS V MCL S
Per: LB MCL S, RB PSL D
Aus: S1S2 single regular murmur (-)
Physical examination
Pulmo:
Insp: simmetrical (+)
Palp: VF (N/N)
Percus: sonor (+/+)
Aus: vesicular (+/+), rhonchi (-/-), wheezing (-/-)
Abdomen:
Insp : distention (-)
Aus : bowel sound (+) N
Pecuss: tympani all abd region
palp : Tenderness in epigastrium (-)
Hepar/Lien unpalpable
Extremities
warm (+/+)
(+/+)
Laboratory Findings CBC (29/04/15)
Tes Hasil Nilai Normal Unit
Lekosit 9,8 4-10 10e3/uL
Eritrosit 4,83 4,5-5,5 10e6/uL
Hemoglobin 13,3 13,0-16,0 g/dL
Hematokrit 40,0 40-48 %
MCV 82,9 80-100 fL
MCH 27,5 26-34 pg
MCHC 33,2 32-36 %
RDW-CV 9,81 11,5-14,5 %
Trombosit 312,0 150-450 10e3/uL
MPV 5,8 7,2-11,1 fL
Neutrofil % 67,5 50-70 %
Neutrofil # 6,6 2-6,9 10e3/uL
Limfosit % 18,4 20-40 %
Limfosit # 1,8 0,6-3,4 10e3/uL
Monosit % 12,5 2-8 %
Monosit # 1,220 0-0,9 10e3/uL
Eosinofil % 0,782 0-3 %
Laboratory Findings Blood Chemistry
(29/04/15)

Reference
Parameter Result Unit
range
KIMIA KLINIK
SGOT 17 U/L 0 - 50
SGPT 18 U/L 0 - 50
BUN 9 U/L 8,00 18,00
Creatinin 0,8 mg/dL 0,60 1,10
Glukosa 310 mg/dL 74 106
ELEKTROLIT
Natrium 131 mmol/l 135-155
Kalium 4,4 mmol/l 3,5-5,5
Chlorida 100 mmol/l 95-105
Electrocardiography
(29/04/15)

Interpretasi:
Irama Sinus reguler
110 kali/menit
Assessment

Hematemesis ec suspect
gastritis erossiva
DM type 2
uncontrol
Planning
Therapy
Gastric cooling
IVFD RL 0,5 % 20tpm
Tranexamic acid 3x 500mg PO
Omeprazole 3x 40mg PO
Sucralfat 3x CI
Glibencamid 5mg 1-0-0

Diagnostic
Endoscopy
Planning Monitoring

Monitoring
Vital sign
Complaint