Ali Amril/Male/69 y.

o/MW 02

Chief Complaint:
• Black defecation since 1 week ago
3
Present Illness History

• Black defecation since 1 week ago

• Bluish bruises on abdomen, lef arm, and waist
since 2 weeks ago
• Pain on upper stomach since 2 weeks ago
• Nausea since 1 week ago, vomit 3 days ago,
containing food and water
• Cough since 4 days ago, phlegm (+)
• Breathlessness since 2 days ago, not affected by
activity, weather and food
• Fever since 2 days ago, not high, not chills, not
sweat.
• Micturition volume and frequency is normal
Cont’d

• Patient has been diagnosed with

heart failure stage B NYHA FC II with
EF 60% since August 2022, and AF
RVR, treated with amiodaron
3x200mg
• Patient has been diagnosed with
Deep Vein Thrombosis since August
2022, treated with warfarin 1x2mg
and aspilet 1x80mg
Past Illness History

• Hypertension (-)
• Diabetes (-)
• History of bloody micturition 4 months ago, had
been referred to urologist with susp prostate
cancer, planned to do TURP and biopsy

Family Illness History

• There is no family member get the similar

disease.
Physical Examination VII

• General Appearance : Moderate

• Consciousness level : Compos Mentis Cooperative

• BP : 131/61 mmHg

• HR : 108x/minute, irreguler

• RR : 24 x/minute

• T : 38,1 C

• SpO2 : 97% with O2 3lpm

• Eye
–Conjunctiva anemic (+)
–Icteric sclera(-)
• Neck
–JVP 5+2cmH20
• Thorax : normochest
• Cor: VII
–Inspection : Ictus is not seen
–Palpation : Ictus is palpable on 1 finger lateral
LMCS ICS VI
–Percussion:
•Left border : 1 finger lateral LMCS ICS VI
•Right border : Linea sternalis dextra
•Upper border: ICS II
–Auscultation: Regular, murmur (-), Gallop S3 (-)
• Lung: VII

–Inspection : Statically & dynamically

symmetric
–Palpation : Fremitus left = right
–Percussion : Sonor
–Auscultation: bronchovesicular, Rh +/+ ,
Wh -/-
• Abdomen:
–Inspection : hematoma +
VII
–Palpation : Hepar and lien are not palpable
–Percussion : tympany
–Auscultation : Bowel sound (+) Normal

• Extremities:
–Odema -/+

Well’s score = 3
Laborator
y Items Value VII
Hb/ht/leuko/trombo 7,6/23/18710/243000
DC 0/0/4/75/15/6
PT/APTT/INR 10,4/36,7/1,11
Ret 3,17
RBG 132
Alb 2,6
Ur/Cr 107/1
Na/K/Cl 134/4,3/100
PBS Anisotosis normochrome, polichrom +
Chest X-Ray VII
ECG VII
Problems
• Melena
• Anemia
• Heart failure
Working Diagnosis

• Melena cb non variceal bleeding

• Moderate anemia normocytic normochrome cb acute bleeding
• Atrial Fibrillation RVR
• Heart Failure Stage B NYHA FC II with EF 60%
• Deep vein thrombosis of left leg
• Community Acquired Pneumonia non severe low risk MDR
• Susp. Prostate cancer
Therapy
• Rest/ Gaster Diet II
• IVFD NaCl 0,9% 12hours/kolf
• Inj lansoprazole 4x30mg IV
• Inj transamin 3x500mg IV
• Inj Vit K 3x10mg IV
• Inj ceftriaxone 2x1 gr IV
• Azithromisin 1x500mg po
• Sukralfat 3x10cc po
• Domperidon 3x10mg po
• Bisoprolol 1x5mg po
• Bandage compression
Plan
• Tranfusion PRC 2 units
• Consult urologist
• Sputum culture