Morning

Report

Departement of Interna
Wednesday September 26 2018
J30
List of Patient
Identity

Name : Mrs. I
Age : 59 years old
Address : Lamongan
Admission : September 26, 2018 22:00
Anamnesis

 CP: Vomiting Blood

 PH: The patient complained vomiting blood since 1 hours before
adm. Vomited 1 times with blackish red color color, about ± 1
glass. The patient also complained his stools being darker since 1
hours before adm. She said that the color of stools like “petis”,
defecated 1 times, it’s about one hand grip. Nausea (+). The
patient took Natrium Diclofenac at 07.00 pm, after that the patient
had upper abdominal pain. Febris (-)
 PHI: DM (-) HT (-)
Illness with the same complaint (+)
 27/6/2015  HM e.c Gastritis Erosive (Leko:8500, Erit:1,8 jt, Hb: 3,5, Tromb:66)
 19/10/2015  HM e.c Gatritis Erossiva san susp. DMPS (Leko:2200, Erit:3,68 jt,
Hb: 11,1, Tromb:70) Endoskopi  Gastritis Erosive
 18/8/2018  HM, Pansitopenia, pre Leukemia (Leko:5200, Erit:2,67 jt, Hb: 7,6,
Tromb:63)  Transfusi PRC 1 kolf  (Leko:2000, Erit:3,29 jt, Hb: 9,2, Tromb:45)
PRIMARY SURVEY

A : Clear, gargling (-), snoring (-), speak fluently (+), potensial obstruksi (-)
B : Spontan, RR 20 x/menit, ves/ves, Rh -/-, Wh -/-, SaO2 99 % tanpa O2 support
C : Akral HKM, CRT < 2’ N 92 x TD 99/57 mmHg
D : GCS 456, lateralisasi-, PBI 3mm/3mm, RC +/+
E : temp 36.3c
– General condition : weak
– Awareness : composmentis
– GCS : 456
– H/N : a +/i-/c-/d -
lymph node enlargement at neck (-)
THORAX

– Inspection
– Symmetrical, retraction -
– Palpation
– Thrill (-), fremitus WNL
– Percussion
– Lungs: sonor / sonor
– Cor: N
– Auscultation
– Lungs: ves /ves, rh -/-, wh -/-
– Cor: S1S2 single, M -, gallop -
ABDOMEN

– Inspection
– flat
– Auscultation
– Met -, bowel sound + N
– Palpation
– Pain (-)
– Liver/Spleen within normal limit
– Percussion
– Tymphany
EXTREMITIES

– Inspection
– Clubbing fingers (-), icteric (-), cyanosis (-), edema (-),
– Palpation
– Warm, dry and pale, CRT <2’
 Laboratory finding
Gula Darah Acak --> Hasil : 125 [ ]
SGOT --> Hasil : 59 [ 0 - 35 ]
SGPT --> Hasil : 29 [ 0 - 35 ]
Lekosit --> Hasil : 3.4 [ 4.0 - 11.0 ]
Neutropil --> Hasil : 67.7 [ 49.0 - 67.0 ]
Limposit --> Hasil : 19.2 [ 25.0 - 33.0 ]
Monosit --> Hasil : 4.0 [ 3.0 - 7.0 ]
Eosinopil --> Hasil : 7.1 [ 1.0 - 2.0 ]
Basofil --> Hasil : 2.0 [ 0.0 - 1.0 ]
Eritrosit --> Hasil : 2.18 [ 3.80 - 5.30 ]
Hemoglobin --> Hasil : 6.8 [ P13,0 - 18,0
L14,0 -18,0 ]
Hematokrit --> Hasil : 20.4 [ L 40 -54
P 35 - 47 ]
MCV --> Hasil : 93.60 [ 87.00 - 100 ]
MCH --> Hasil : 31.20 [ 28.00 - 36.00 ]
MCHC --> Hasil : 33.30 [ 31.00 - 37.00 ]
RDW --> Hasil : 14 [ 10 - 16.5 ]
Trombosit --> Hasil : 62 [ 150 - 450 ]
MPV --> Hasil : 7 [ 5 - 10 ]
Laju Endap Darah 1 --> Hasil : 41 [ 0 - 1 ]
Laju Endap Darah 2 --> Hasil : 72 [ 1 - 7 ]
Assessment

 Hematemesis Melena
 Anemia
 Leukopenia
 Thrombocytopenia
 Pre Leukemia
Therapy

 Inf RL 1500cc/24 Jam

 Inj Antrain 3x1gr
 Inj Panloc 2x40mg
 Inj Ceteron 8mg Prn
 Pro Transfusi PRC 2 kolf