DEPARTEMENT OF INTERNIST

Emergency care unit, jan 10 (02.00 pm- 07.00 am)

 Name Age Address Lamongan

: :

Mr. Ngalim : 51 YO Kedungdadi Sugio

Work

Private worker

ANAMNESIS
Chief complaint: black stool History of present illnes: Patient complaint he had black stool as petis since 5 days before hospitalized. Defecation 3 times a day with abdominal pain especially in umbilical area. Pain continuesly. Nause and vomitting since 5 days before hospitalized. Vomit 2-3 times a day, color black, mixed food. After all he got headache and body weakness. Yesterday (1 day before hospitalized) he brought to Blawi Polyclinic and he didntt feel better.

History or pass illnes: History of DM (3 years) , HT (-), History of family: denied History of sociality: Smooking , drinking coffee, traditional medicine

 Physical examination: General status GCS : 456 Vital Sign: BP : 90/47mmHg Pulse : 104/mnt Temp : 36,70C RR : 20/mnt Head/neck An+, ict- cyan-, dys JVP normal

Thoraks Symmetric, retraction () Cor : S1 S2 single, murmur (-), gallop (-) Pulmo: ves/ves, rh -/-, wh -/Abdomen Supple, right lower abdominal pain (less), thimpany, bowel sound (+) N, Extremity cool, wet, oedema -, eritema palmaris -,

Laboratory Findings
Diff count: 1/0/78/16/5 Hematocrite: 15,9 % Hb 5,3 mg/dl LED 89/119 Leukocytes : 12.900 Thrombocyte : 228.000 Albumin 2,8 Globulin 2,1 Total protein 4,9 Alkali fosfatse 168

SGOT 10 U/L SGPT 13 U/L Clorida serum 105 Kalium serum 5,3 Natrium serum 133 Creatinin serum : 1,8 mg/dl Urea 188 Uric Acid : 6,8 mg/dl GDA : 229

CLUE AND CUE

Male, 51 yr Abdominal pain Melena Nausea & Vomit Headache Fatigue Hypotension (90/47mmHg) Tachicardia (104/m) Abdomen Supple, right lower abdominal pain (less), Extremity cool, wet, pale, oedema -, eritema palmaris Hb 5,3 mg/dl Leukocytes : 12.900 Natrium serum 133 GDA : 229

RESUME
Patient, Male 51 YO, with black stool and abdominal pain 5 days before hospitalized. He felt fatigue and headache then. Drinking traditional medicine jamu even 8 times a day. BP : 90/47mmHg, Pulse : 104/mnt, anemis +, right lower kuadran abdominal pain (mild), extremity cool, wet, pale Hb 5,3 mg/dl Leukocytes : 12.900 Sodium 133 Random Blood Sugar : 229

Problem List: -Acute Abdominal Pain -Hypovolemic Shock -Hyperglicemia -Anemia Planning Diagnosis DL, RFT, LFT, HbA1c Endoscopy USG Abdomen

Initial Diagnosis Haematemesis Melena e.c Acute Gastritis Erosiva Hypovolemik Shock DM type 2

Planning Therapy O2 nasal 3lpm IVFD Asering loading 2000cc (20-40ml/kgBB) NGT DC Ranitidin IV 2x50mg Metamizole 3x500mg Pantoprazole bolus 2x 40 mg 8mg/hour (syringe pump 4 amp/24 hours) Tranexamic Acid 2x250mg Transfussion (PRC) RCI 4U

MONITORING
Vital signs Urinase Complaint Hb, Electrolite serum

PROGNOSIS
Dubia ad bonam