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Hazirah binti Harun Rusannah binti Abu Samah Dr. Shinta Oktya W. , Sp.

PD

Summary of Data Base


Mrs. M / 85 y.o/ W 28 Chief Complain : coffee ground vomiting Patient suffered from coffee ground vomiting since 2 days before admission, 1 time a day, with the volume more than one glass.

Prior to the vomiting, she felt nausea. She also complained about
blacktarry solid stool since 2 days ago, 1 time a day. She did not complain about abdominal pain but she he had decreased of appetite. She also suffered from headache after the first time she vomited, accompanied by general weakness.She went to general practitioner and she had given 2 types of medicines. The doctor

asked her to go to hospital but she didnt go. After she vomited
again on the next day, her family took her to RSSA.

Patient also seldomly suffered from low back pain since some years ago. Medicine consumed (painkiller).

History of liver disease (-)


History of Diabetes mellitus (-)

History of Gastritis (-)


History of Hypertension (+) 3 years ago, controlled a few times, then never had HT after that

Physical examination
BP = 110/60mmHg Head Neck Thorax: Cor: PR = 96 bpm irreguler Anemic + JVP R + 0 cm H2O Ictus invisible and palpable MCL ICS V Sinistra 1 cm lateral RHM SL Dextra LHM ictus S1 S2 single, murmur Lung: Symmetric SF D=S SS SS SS VV VV VV Rh - - - Wh - - - RR = 20tpm GCS 456 Icteric Inserted NGT : bloody + Tax = 37.0 C General appearance looked moderately ill

Abdomen Extermities RT

Flat, Soefle,, liver span 8cm, troube space thympani, shifting dullness -, BS + Warm, edema -, pale extrimity + Sphincter ani no abnormality, , Melena -

Laboratory findings
Lab
Leukocyte

Value
14 700 3.500-10.000/L

Lab
Natrium Kalium
Chlorida

Value
134 4.12
116

136-145 mmol / L 3,5-5,0 mmol / L


98-106 mmol / L

Haemoglobine

3.6

11,0-16,5 g/dl

MCV
MCH RBC
PCV Trombocyte

65
19.9 1.78x106
11.6 359 000 35-50% 150.000390.000/L

albumin
RBS PPT aPTT SGOT SGPT

3.08
153 12.4 23.7 16 11

3.5-5.5
K:11.9 K:27.3
11-41 U/L 10-41U/L

Ureum Creatinine

72.1 0.76

10-50 mg/dL 0,7-1,5 mg/dL

UL: eritrocyte

2+

ECG 1/4/2012
Sinus rhytm, heart rate 97 bpm Frontal Axis : Normal Horisontal Axis : normal PR interval : 0.12'' QRS complex : 0.08 QT interval : 0.36 Conclusion : sinus rhytm, heart rate 97 bpm

CXR 1/4/2012)
Thorax AP position, asymetric, less inspiration, KV is not enough Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are blunt Right hemidiaphragma and left hemidiaphragm are dome shape Lung : Cor site and shape are normal, CTR: 60% Conclusion: cardiomegaly

Lumbasacral AP/Lateral position Soft tissue normal Bone: disalignment Intestine: Air (+) feces (+)
Conclusion: Scoliosis Lumbalis

Female/85 yo Vomit of coffee ground appearance, volume: more than a glass Blacktarry stool Headache Took painkiller for back pain (unknown) PE: Anemic conjunctiva NGT : hematemesis Extrimity: pale RT: melena -

1.Hemate mesismelena

1.1. NSAID gastropathy 1.2 Ruptur VE

Endoscopy

Fasting NGTGastric lavage/8 hours1 times negative/cleanstart liquid diet 6x200cc (1cc=1kcal) IVFD NaCl 0,9% 30-40 dpm Omeprazole 1x40 mg iv Inj metoclopramid 3x10mg

Subjec tive BP HR Hemat emesis melena

Female/85 yo Ax: General weakness,pale PE: Anemic conjunctiva+ Pale in all extrimities Hb 3.6 MCV= 65 MCH=19.9 RBC=1.78x106

2. Anemia gravis Hypochro m microcyter

2.1 Chronic bleeding 2.2 Chronic disease

Blood smear, SI/TIBC

Transfussion PRC 500 cc/day untill Hb8g/dL

Hb, VS, Subjec tive

Female/85 yo Felt pain on her back (seldom) Took painkiller (unknown) Photo Lumbosacral AP/Lateral- scoliosis lumbal

3. Low Back Pain

3.1 Degenerative Osteoperosis 3.2 idiopathic scoliosis

Education: avoid trauma

Female/85 yo General weakness Ur: 72.1 Cr: 0.76

4. Azotemia

4.1 Pre renal 4.2 Renal

Treat underlying disease

Urine produc tion