Morning Report

April, 14th 2015

Kresna Septiandy
Cristian Rajagukguk

SPV : dr. Nur Samsu, Sp.PD-KGH

 Summary of Data Base
Mr. Suwono /68yo/w.26
Heteroanamnesa from his wife
Chief complaint: black tarry stool

Patient suffered from black tarry stool since 6 days before admission, 4-6 times per day,
the fluid consistency dominant than soft consistancy with black tarry like coloured, the
volume about a half of glass.

He also suffered from abdominal discomfort and felt fullness of his stomach, since 3
weeks ago. He had difficulty of passing stool about 2 weeks. Although he ate some
meal about a half portion each meal, he still coludnt passing stool. He suffered from
decrease of appetite since then.

He passing urine with yellow coloured, normally.

Actually about a week ago, his family brought him to private hospital with the same
complain. He admitted there for 7 days. Because the complain didnt improve yet, and
the condition worsen, the patient started couldnt communicate well, the doctor advise
him to referred to RSSA.
History of past ilness

This was the 4th hospitalization.

The 1st and the 2nd hospitalisation at private hospital about urination problem. He had performed
prostat surgery 4 years ago.

The 3rd hospitalisation. He suffered from black tarry stool and epigastric pain. He hospitalised at
RSSA, had performed endoscopy. The results was gastric ulcer.

History of medication:

There was no drug that he consumed routinely.

History of family:

No family that have same illnes with him.

History of hypertension, diabetes, nor liver disease in his family, were denied.

History of privation and social:

Patient married, had 2 children, the last children was junior high school.

He work as factory farmer. History of contact with chemical agent (+), pesticide.

He smoked a half until 1 pack (5-10 cigarrette) for 20 years, but already stopped since 10 years
ago.

History of consume alcohol, tatto, iv drug user, multiple partner sexual were denied.

History of blood tranfussion (+)

 Physical examination
General appearance looked severely ill GCS 334
BP = 140/100 mmHg(ward) PR = 104 bpm, regular, RR = 22 tpm Tax = 36,4C
strong
Head and Neck Pale conjungtiva(+) JVP R+3 cm H2O, 300
Iketrik sklera (-) Dry mouth mucosa (-)
Thorax: Normal chest wall, spider nevi (-), gynecomastia (-)
Cor: Invisible and palpable at ICS V and MCL S
RHM SL sinistra
LHM ictus
S1, S2 single with no murmur
Lung: Symmetric, SF D = S v v Rh - - Wh - -
v v -- --
v v -- --
Abdomen Soefl, BS (+) normal, liverspan 7 cm, traubes space tympani,
shifting dullness (-)
Extremities Warm, extremity edema -/- pitting. Palmar erithema (-)
-/-
Rectal touche Sulcus medianus palpable. Palpable mass (-). Round surface smooth.
Melena (+)
 Laboratory Findings
Lab Result Normal Value Lab Result -Normal Value

Leukocyte 10.240 3,500-10,000/L Sodium 141 136--145 mmol / L

Hemoglobine 9.5 11.0-16.5 g/dl Potassium 4.0 3.5-5.0 mmol / L

MCV 82.2 80-97 m3 Chloride 114 98-106 mmol / L

MCH 26.0 26.5-33.5 m3 275-285

PCV 30.1 35-50% RBS 99 <200 mg/ dL

Thrombocyte 79.000 150,000- Ureum 56.8 10-50 mg/dL

390,000/l
SGOT 196 11-41U/L Creatinine 1.04 0.7-1.5 mg/dL
BUN/Cr
SGPT 93 10-41U/L Protein total 5.81 6.7-8.7

PPT 15.3 9.3 11.4 Albumin 2.80 3.5-5.5 g/dL

INR 1.46 0.8 1.3 globulin 3.01 2.5-3.5

aPTT 35.5 24.8-34.4 Bilirubin total -

Bilirubin direct -
Bilirubin -
indirect
 Urinalysis (perform at previous hospital april 8th 2015)

Lab Value Lab Value

Urinalysis 10 x
SG 1.025 Epithelia -

PH 6.0 Cylinder -

Glucose Negative Hyaline

Protein Negative Granular -

Keton Negative 40 x
Bilirubin Negative Erythrocyte Uncountable

Urobilinogen Negative Dismorfik

Nitrit Negative Eumorfik

Leucocyte Trace Leukocyte 5-7

Blood +3 Crystal Negative
Bacteria +
 BLOOD GAS ANALYSIS WITH NRBM 10 LITERS/MINUTE
pH 7.41 7,35-7,45
pCO2 29.1 35-45 mmHg
pO2 192.9 80-100 mmHg
HCO3 18.5 21-45 mmol/L
BE -6.4 (-3) ( +3) mmol/L
O2 saturation 99.3 >95 %
True O2 40.5

BGA conclusion Metabolic acidosis fully compensated respiratoric alcalosis,

with moderate hypoxemia
CXR
 CXR

AP position, asymmetric, KV enough, enough inspiration

Soft tissue normal, bone normal
Trachea in the middle
Right and left hemidiaphragm were dome shape
Costo phrenico angel d/s were sharp
Right and left lung: normal bronchovesicular pattern
Cor: site normal, size 45% apex embedded, cardiac waist (+)

Conclusion : normal
Ro Thoracolumbal AP/Lat
April 8th 2014
ECG
 ECG
Sinus tachycardia, Heart rate 100 bpm
Frontal Axis : normal
Horizontal Axis : normal
PR interval : 0.16
QRS complex : 0.08
QT interval : 0.36
PRWP poor r wave progresion at lead V1-V2

Conclusion :
Sinus tachycardia, Heart rate 100 bpm ,ischemia anterior wall
Endoscopy
August 14th 2014

Conclusion:
Gastroduodenitis errosive
with gliant ulcer
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. Suwono /68yo/w.26 1. Acute Patency airway, breathing, circulation Monitoring:
confusional Bedrest Subjective
melena since 6 days ago before state O2 8-10 lpm nasal canule Vital sign
admission, Insert NGT Melena
Difficuly of passing stool about 2 Precipitating with Gastric lavage / 8 hours 1 times Bleeding
weeks dementia and clear start fluid diet 6x200 cc manifestation
Decrease of appetite severe illness
History of performed endoscopy Rehydration with Nacl 0,9% 500cc Education:
with results gastric ulcer continued with NaCl 0,9% - 30 dpm Fasting first until 1
History of smoking times clear gastric
Oral and personal hygiene lavage
Physical examination Start with fluid
Pale conjungtiva (+) diet
RT: melena (+)
Liver span 7 cm

Laboratory findings:
Hb 9.5
MCV 82.2
MCH 26.0
BGA: true O2 40,5% moderate
hypoxemia
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. Suwono /68yo/w.26 2. Melena 2.1 Endoscopy Bedrest Monitoring:
gastroduodenitis O2 2-4 lpm nasal canule Subjective
melena since 6 days ago before errosiv with giant Insert NGT Vital sign
admission, ulcer Gastric lavage / 8 hours 1 times Melena
Difficuly of passing stool about 2 clear start fluid diet 6x200 cc Bleeding
weeks manifestation
Decrease of appetite 2.2 rupture Rehydration with Nacl 0,9% 500cc
History of performed endoscopy Varisces continued with NaCl 0,9% - 30 dpm Education:
with results gastric ulcer Esophagus Fasting first until 1
History of smoking 2.2.1 due to Bolus lansoprazole 60 mg intravenous times clear gastric
cirrhosis hepatis (insert 2 vial lansoprazole @40 mg in lavage
Physical examination 100 cc NaCl 0,9% - 20-30 minutes Start with fluid
Pale conjungtiva (+) Continued with drip lansoprazole diet
RT: melena (+) 8mg/hour
Liver span 7 cm (insert 2 vial of lansoprazole @40 mg
in 500 cc NaCl 0,9% - 20 dpm)
Laboratory findings:
Hb 9.5
MCV 82.2
MCH 26.0
Trombocyte 79.000
SGOT 196
SGPT 93
Albumin 2.8

Endoscopy August 2014

Gastroduodeintis errosive with
giant ulcer
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. Suwono /68yo/w.26 3. Cirrhosis 3.1 post necrotic HBsAg Diet liver 1800 kcal / day Monitoring:
hepatis hepatitis B AntiHCV Equal fluid balace Subjective
Decrease of appetite infection Vital sign
History of performed endoscopy Confirm diagnosis
with results gastric ulcer 3.1 post necrotic
History of smoking hepatitis C
melena since 6 days ago before infection
admission,
Difficuly of passing stool about 2
weeks
History of blood tranfussion (+)

Physical examination
Pale conjungtiva (+)
RT: melena (+)
Liver span 7 cm

Laboratory findings:
Hb 9.5
MCV 82.2
MCH 26.0
Trombocyte 79.000
SGOT 196
SGPT 93
Albumin 2.8

Endoscopy August 2014

Gastroduodeintis errosive with
giant ulcer
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. Suwono /68yo/w.26 4. Low back pain 4.1 spondilosis Paracetamol 3x500mg Monitoring:
4.2 Subjective
Back pain since 2 years ago spondiilolitshesis Vital sign
Consume pain killer 4.3 HNP

Ro thoracolumbal:
Spondilosis, spondilolithesis

Mr. Suwono /68yo/w.26 5. HT st II Low salt diet <2g/day Subjective

Amlodipin 1x10mg Vital sign
History of smoking Captopril 3x12,5mg
BP 140/100mmHg
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