November 14th ,2017

dr. Rudi Erwin

 Afnida, Female, 29yo, FW21

 Cc:

 Black stool since 1 month ago.

 Present Illness History

 Black stool since 1 month ago. Frequency 1-2x/days. Liquid and black like
asphalt.
 Nausea and vomite denied.
 Cough since 1 month ago. Sputum (+) and white color. Bloody cough (-).
 History of night sweats without physical activity (+).
 Decreased of appatite (+)
 Decreased of bodyweight (+)
 Fever denied
 History of prolonged menstruation denied
 Red spots at both of arms since 2 weeks ago.
 Patient referred from Pariaman hospital and has been done Red blood
transfusion 4 unit and white blood transfusion 10 unit.
 Micturation was normal
 
Past Illness History
• History of Malaria (-)
• History of DHF (-)

Family Illness History

• Nothing family with blood disorders
 Physical Examination

 Consciousness level : CMC

 BP : 130/80 mmHg

 HR : 92x/minute

 RR : 20 x/minute

 T: 36,7 C
 Eye
 Conjunctiva are anemic +/+
 Sclera are icteric -/-

 Neck
 JVP 5-2 cmH20

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: left = right fremitus
 Percussion: dull
 Auscultation: Bronchovesicular, rales +/+ at upper to
middle both of lung, wheezing -/-
 Cor:
 Inspection: ictus not seen
 Palpation: ictus is palpated at 1 finger medial LMCS RIC V
 Percussion:
 Left border: 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: RIC II
 Auscultation: pure rhythm, no murmur
Abdomen:

 Inspection: enlargement (-)
 Palpation: liver palpabl and spleen no palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Superior : Red spots (+)
 Inferior : Oedema +/+
 Laboratory

Hb  10,0 gr/dl
Ht 30%
WBC 5.460/mm3
Platelet 31.000/mm3
MCV/MCH/MCHC 75/25/33
Ur/Cr 25/0,4
Na/K/Cl/Ca 137/2,3/96/5,6
RBG 97 mg/dl
Alb/Glb 2,0/1,8
PT/aPTT 13,3/42,9

 Working Diagnosis

 Melena cb Trombocytopenia cb Susp. ITP
 Mild anemia microcytic hypochrome cb chronic
disease
 Susp. Lung tuberculosis
 Hypokalemia cb transeluler shift
 Hypocalsemia cb hypoalbuminemia

Dd/
 Melena ec peptic ulcer
 Evan’s syndrome
 Aplastic anemia
 Malaria
 Therapy

 Rest/ NGT flow fasting 8 h  Gastric diet I/O2 2L/1’
 Bolus lansoprazole 60mg (IV)
 Drip lansoprazole 60mg in 500cc NacL 0,9% finished 10
hours
 Correction of albumin 20% 100cc
 Correction of KCL 25 mEq in 200cc NacL 0,9% finished 4
hours
 Drip Ca gluconas 3000 mg in 200cc NacL 0,9% finished 4
hours
 Transfusion of thrombocyte 10 unit
 N-acetylsistein 3x200 mg (po)
 Sucralfat syr 3xcth II (po)
 Planning

 EGD
 BMP
 Acid resistant bacteria sputum
 Hepatic marker