Morning Report

Coass in charge :
Natasya Tanjaya
Dyah Ayu
Bunga Bella
Maulidya Savitri
Mia Fajarningtyas
Nurul Islam MKP
Ayu Rizky

Supervisor :
dr. Laksmi, SpPD
Case
Mrs.H/Female/65yo/W.26
SUMMARY OF DATA BASE
Mrs.H/Female/65yo/W.26
Autoanamnesis Heteroanamnesis
Chief complain : bloody vomit
Present Illness :
Patient was admitted to RSSA because of bloody vomiting 3 times since 5 hours
before admission. The amount of the vomit was about 6 glass. She also
complain she has bloody stool since one day before admission with soggy
consistency. She had bloody stool since 2 years ago, but she wasnt go to
health care for treatment.
She complained about epigastric pain since 1 year ago. Everytime she felt pain,
she was consumed omeprazole and Mylanta to reliefed the pain. She also
complain for headache and toothache since 3 months ago, and everytime
she felt pain she take binahong leaf 2 capsuls/day.
She has diabetes mellitus since 10 years ago, and she routinely control to
doctor. She was given metformin 2x500 mg. But her bloody sugar was
uncontrolled, so she was given novomix 2 times in the morning and night
since 6 months ago.
 SUMMARY OF DATA BASE

PAST MEDICAL HISTORY

He had hospitalization 2 weeks ago for 4 days because of same chief complained.
She usually getting tranfussion when hospitalization .

FAMILY HISTORY

His sister has a history of Hypertension.

SOCIAL HISTORY

He had history of consumed alcohol once a year, about a half glass.

He was a smoker. But he stop to smoke for recent 2 years.

REVIEW OF SYSTEM

Urination : tea-like appearence since 1 years ago

Passing stool : Blacktarry stool intermitently since 2 years ago.

 Physical Examination
General Appearance: looked moderately ill

GCS: 456 BP : 110/60

HR : 98 bpm regular RR : 20 tpm Tax 36.5 C
mmHg

Head Anemic conjunctiva (+) , icteric sclerae (-), pupil isocor. Oral thrush (-)
Neck JVP: R + 0 cm H2O in 30 position.
Wall Chest expansion symmetric.
S1 and S2 single
Chest Ictus invisible,
Heart palpable at ICS V MCL S
RHM ~ SL D
LHM ~ ictus
Stem Fremitus D=S V V Rh - - Wh - -
Lung VV - - - -
VV - - - -
Rounded, bowel sound (+) n, shifting dullness (+), Striae (+) liver span 8 cm, regular
Abdomen edge, tenderness at epigastric (-), troubspace tymphany
RT : Melena (+)
Warm, edema -/- , pale
Extremities
-/-
 Laboratory finding
Laboratory Result Normal Value Laboratory Result Normal Value
Hb 5.8 13,4 17,7 g/dL Anti HCV Negative
Leucocyte 12.600 4.300-10.300/L RBS 300 < 200 mg/dL
Hematocrit 18,90 40 47 % Natrium 130 136 145 mmol/L
Thrombocyte 137.000 142.000- Kalium 4.89 3,5 5,0 mmol/L
424.000/L
MCV 82.20 80 93 fL Chloride 105 98 106 mmol/L

MCH 25.20 27 31 pg Ureum 60.70 16.6 48.5 mg/Dl

MCHC 30.70 32 36 g/dL Creatinine 0.69 < 1.2 mg/dL
Differential 0.0/0.2/80.3 0-4/0-1/51-67/25- Bilirubin Total 0.73 < 1.0 mg/dL
count /14.7/4.8 33/2-5 %
SGOT 32 0-40 U/L Bilirubin Direk 0.44 < 0.25 mg/dL
SGPT 37 0-41 U/L Bilirubin Indirek 0.29 < 0.75 mg/dL
Albumin 2.78 3.5 5.5 g/dL hbsAg Non-
Reaktif
ECG
 ECG INTERPRETATION
Sinus rhythm
Heart Rate : 100 bpm
Frontal axis : normal
Horizontal axis : counter clockwise
PR interval : 0.12 s
QRS complex : 0.06 s
QT interval : 0.32 s
T inverted at V1 V4
Conclusion : sinus rhythm with HR 88 bpm, LVH
CXR:
CXR normal
AP position, asymmetric, strong KV, less inspiration
Soft tissue and Bone normal
Trachea in the middle
Hemidiaphragm D was covered by radioopaque shadow
and S was flat
Phrenico costalis angle D was covered by radioopaque
shadow and S were blunt
Pulmo D was covered by radioopaque shadow
Cor: site Normal, size CTR could not be evaluated

Conclusion : Right pleural effusion

 CUE AND CLUE PL Idx PDx PTx PMo PEd
Female/65 yo/ 1. 1.1 Ruptur Endoscop - Fasting Bloody Planni
A: Hemate Varises y NGT GL/8hours if vomiting, ng for
- Bloody vominting, mesis + esophagus clear start fluid diet Melena, endos
blacktary stool since 2
days
melena 1.2 Peptic 6x200cc , low salt < 2 NGT copy
-Abdominal ulcer gram/day producti
enlargement bleeding IVFD NS 0,9% 20 tpm on, HR
-History of tranfussion 1.3 Gastritis Inj Ocreotide 50 mcg decrease
- History of consumed erosive drip 50 mcg/hour d20 %
alcohol Inj Metoclopramid 3x 10 than
- Mother has hepatiif mg fefor,
PE:
- Palmar erythem,
Inj Lansoprazol 1x 30 mg Blood
terrysnail PO : pressur.=
- Pale conjungtiva Ciprofloxacin 2x500 mg r==
- Liver span 14 cm
with irreguler edge,
hard concistency,
shifting dullness (+)
- Splenomegaly
schuffner 3/8
Adominal USG:
Hepatosplenomegaly,
ascites
Lab:
Hb 6.7 g/dL
PLT 156000/Ul
Albumin: 2.52 g/dL
Globulin : 3.97 g/dL
 CUE AND CLUE PL Idx PDx PTx PMo PEd
Male/40 yo 2. 2.1 dt post Biopsi Confirm diagnosis Bloody Planni
A:
- Bloody vominting, Cirrhosis necrotic Gamma Plan to give inj vomiting, ng for
blacktary stool since 2 days hepatis hepatitis B GT, ALP, furosemid 3x40 mg after Melena, endos
- Had sign and symptom of child pugh infection AFP bleeding stop NGT copy
liver disease since 3
months. B with PO: producti
-Abdominal enlargement malignant - Spironolacton 0- on, HR
-History of tranfussion degenratio 100mg-0 (postponed) decrease
- History of consumed
alcohol n - Propranolol 2 x 10 mg d20 %
- Mother has liver disease (postponed) than
PE: fefor,
BP 110/70 mmHg
HR 85 bpm Blood
- Palmar erythem, pressure
terrysnail
- Pale conjungtiva
- Liver span 14 cm with
irreguler edge, hard
concistency, shifting
dullness (+)
- Splenomegaly schuffner
3/8
Adominal USG:
Hepatosplenomegaly,
ascites
Lab:
Hb 6.7 g/dL
PLT 156000/Ul
Albumin: 2.52 g/dL
Globulin : 3.97 g/dL
HbsAg (+)
 CUE AND CLUE PL Idx PDx PTx PMo PEd
Male/40 yo 3. 3.1 Chronic Blood - PRC tranfussion 2 Tranfusio Planni
A: Hypochro disease smear, packs/day until Hb> 8 n ng for
- Bloody vomitting, m 3.2 Fe reticuloc g/dl reaction, tranfu
blacktary stool since microcyte deficiency yte Hb post sion
2 days r anemia count, tranfusio
- History of Fe, Si, n
tranfussion TIBC
PE:
- Pale conjungtiva
- Liver span 14 cm
with irreguler
edge, hard
concistency,
shifting dullness
(+)
- Splenomegaly
schuffner 3/8
Lab:
Hb 6.7 g/dL
MCV 78.90 fL
MCH 23.60 pg
 CUE AND CLUE PL Idx PDx PTx PMo PEd
Male/40 yo 4 Natrium -Inj Furosemid 3 x 40 mg Natrium/ Increa
Hiponatrem urine iv (after bleeding stop) 3day sed
Laboratory: i the
Na: 128 mmol/L hypoosmola frequ
Osm 272 mOsm r ency
Euvolemi of
dt. urinat
Dilutional e
 CUE AND CLUE PL Idx PDx PTx PMo PEd
Male/40 yo 6. Right Pleural - Plan to evacuate pleural Planni
pleural fluid fluid ng for
PE: effusion culture evaku
- Dullness at right and ate
pulmo sensitivit his
- SDV D<S y test pleura
CXR : Right pleural l fluid
effusion
THANK YOU