Summary of Data Base

Mr. Huzaini / 53 yo /w.26

Anamnesis
: Autoanamnesis
Chief Complaint : Black tarry stool
Patient suffered from black tarry stool since 5 hours before
admission, blacktarrystool 4x

about one glass of mineral

water each, soft consistency, faulty odor, didnt accompanied

by fresh blood and mucus.
He also complained about vomiting, red colored, 1x, 2-3
spoonful, consisted of water and food remains at 5 hours
before admission, happened before black tarry stool.
Last year He perform ligation for treatment his bleeding.

 He diagnosed Hepatitis C infection since 3 years ago, and

routinely controlled at Gastro outpatient clinic at RSSA, He
got Lesichol 2x1 and propranolol 2x1 for the treatment

Family History

: His parents already passed away,

has 8 siblings, No one in his family has history of jaundice;

chronic liver disease.
Past Medical History

: hospitalized 13 times with the

same complained
Social history

: He was married, has 4 children.

Physical Examination
General appearance: looked moderately ill

GCS 456

BP = 100/60 mmHg

PR = 62 regular,
strong

RR = 18 tpm,

Head

Anemic conjunctiva
(+)
Icteric sclera (-)

Neck

JVP R + 0 cmH2O at 30

Chest

Heart:
Lung:

VAS: 0/10

Tax : 36.5 C

lymphnode enlargement (-)

Ictus invisible and palpable at ICS V 1 cm lateral, MCL Sinistra

Stem Fremitus D=S

S S V V Rh - SS V V
- SS V V
- -

Wh - - - -

Abdomen and Genital flat, soefl, bowel sound normal, epigastric tenderness (-), liver
span 8 cm, Traubes space : dull
Sphincter tonus (+), mucosa: smooth, sulcus medianus palpable, melena (+)
Rectal Toucher
Extremities
Urine output

Oedema

-I-I62.5 cc/hrs

Laboratory Finding, July 6th 2015

Lab

Value

Lab

Value

Leukocyte

11,270

3,50010,300/L

Natrium

130

136-145
mmol / L

Hemoglobine 7.00
MCV
75.80

11.0-16.5
g/dl
80-97 fL

Kalium

5.03

3.5-5.0 mmol /
L

MCH

22.00

26.5-33.5
pg

Chlorida

111

98-106 mmol /
L

PCV

24.10

35-50%

Albumin

3.00

3.5-5.5 g/dL

Trombocyte

81,000

140,000424,000/L

RBS

134

<200

Eu/bas/Neu/L 0.0/0.1/77.3/16.5/6.1 %
y/Mo

SGOT

37

0-41U/L

Ureum

85.30

10-50
mg/dL

SGPT

22

0-41U/L

Creatinine

1.11

0,7-1,5
mg/dL

CXR, Marc 30 2015

th

CXR Interpretation
AP position, asymmetric, enough KV, less
inspiration
Soft tissue and Bone normal
Trachea in the middle
Hemidiaphragm D and S were dome shaped,
Phrenico costalis angle D and S were sharp
Pulmo D/S: Increased BVP
Cor: site Normal
Conclusion :

normal CXR

ECG, March 30th 2015

ECG Interpretation

Sinus Rhythm, Heart rate 70 bpm

Frontal Axis
: normal
Horizontal Axis : counter clockwise rotation
PR interval
: 0.16
QRS complex : 0.04
QT interval
: 0.36
Conclusion : sinus rhythm with HR 70 bpm,

CUE AND CLUE

Male/53 yo
Ax:
-Black tarry stool
since 5 hours before
admission
-History of Hep C
infection
PE:
-BP: 110/70 mmHg
-PR: 80 tpm
Inserted NGT:
brownish
RT: Melena +
Lab:
-Hemoglobin : 7.00
g/dL
-MCV : 75.80 fl
-MCH : 22.00 pg

PL
1.
Hemateme
sis +
Melena

GIDx
1.1 Ruptur
VE
1.2
Pud
1.3 Gastritis
errosive

PDx

PTx

Pmo &
Pedu

Endoscop
y

-Inserted NGT
Gastric Lavage
3xclear Fluid diet 6 x
200 cc via NGT
-Inf. NaCl 0,9% 20
tpm
-Inj. Lanzoprazole
1x30mg
-inj. Metoclopramid
3x10mg

-Subjective
-Vital sign
(BP, PR)
-Gastric
lavage/8
hours
-melena

CUE AND CLUE

PL

GIDx

PDx

Male/53 yo
Ax:
-history of sakit
kuning 4 years ago
-History of Heapatitis
C Infection 3 years
ago

2. Cirrhosis
Hepatis

2.1 Hepatitis
C infection

Endoscop
y

PE:
-BP: 110/70
mmHgsakit kunit 4
years ago
-PR: 80 tpm
Inserted NGT:
brownish
RT: Melena +
Lab:
-Hemoglobin : 7.00
g/dL
-MCV : 75.80 fl
-MCH : 22.00 pg

PTx
Treat underlying
disease

Pmo &
Pedu
-Subjective
-Vital sign
(BP, PR)

CUE AND CLUE

Male/53 yo
Ax:
-Black tarry stool
and bloody
vomiting since 5
hours before
admission
Pe :
-BP: 100/60
mmHg
-PR: 62 tpm
-Conjunctiva
anemic (+)
Lab:
-Hb : 7.00 g/dL
-MCV : 75.80 fL
-MCH : 22.00 pg

PL
2. Anemia
hypokrom
microcyter

IDx
2.1 chronic
disease
2.2 chronic
blood loss

PDx
Ferritin,
SI, TIBC

PTx

Pmo &
Pedu

Plan to give PRC

transfusion until Hb >
8 g/dL

-Subjective
-Vital sign
(BP, PR)
-CBC after
transfusion
-Transfusion
reaction

Pedu:
Treatment,
underlying
disease,
prognosis

CUE AND CLUE

Male/52 yo
Ax :
- Liver disease
since 3 years ago
Pe:
BP: 100/60 mmHg
Albumin : 3.00 g/dl

PL
3.
Hypoalbu
minemia

IDx
3.1
Hypercatab
olic state
3.2 Low untake

PDx

PTx
High Protein diet

Pmo &
Pedu
Subjective
Vital sign
(BP)
Pedu:
Treatment,
underlying
disease,
prognosis

CUE AND CLUE

Male/52 yo
Ax :
- Nausea and
vomiting
BP: 100/60 mmHg
Ureum : 85.30
mg/dl
Creatinin : 1,11
mg/dl

PL
5.
Azotemia

IDx
5.1 volume
depletion
5.2
Hepatorena
l syndrome

PDx

PTx

Pmo &
Pedu

Rehydration 1 L at ER,
continue IVFD NaCL
0,9% 20 dpm

Subjective
Vital sign
(BP)

Avoid nephrotoxic
agent
Equal fluid balance

Pedu:
Treatment,
underlying
disease,
prognosis

Thank You