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By : CYNTHIA NATALIA 03007054
• • • • • • • • • Name Age Sex Education Occupation Religion Marital status Admitted Taken from : Mr. S : 51 years old : male : elementary school : Labour : Islam : Married : March 6th 2012 : Rengasdengklok
occurred since two days before hospitalized.HISTORY TAKING MAIN COMPLAINT Black excreta accompanied by blood. SIDE COMPLAINTS Fatigue Nausea Vomitus Epigastric pain Headache .
It had been two days since patient felt fatigue. . and its excrement black in color with soft consistency. around 500 cc in amount. Additionally. Fatigue alowly increased and ended up disturbing his activities. and there were no phlegm detected. Defecation occurred two days daily. patient also suffered from excruciating stomachache as well as occasional.HISTORY OF PRESENTING COMPLAINT A patient came to Karawang City Hospital’s Emergency Room (UGD RSUD Karawang) on March 6TH 2012 with chief complaints of black and bloody excrements that had occurred since two days before hospitalized. devoid of roughness or liquid. especially when patient consumes spicy or sour-flavored food.
Since the lost of appetite. cold and coughing. and without he feeling of releasing sand. Vomiting took place three times a day. fairly transparent. Patient does not take any blood supplement medication. Patient admits decrease in appetite. Patient’s urine is yellow in color. . from three times of meal to two times of meal daily. as well as headache.Patient also suffered from nausea and regular vomiting. Urination occurred five times a day and painless. filled with bloodless ingested food. bloodless. Patient denies any fever. patient felt his body weaken. Headache is suffered specifically in the back of the head and nape area. shortness of breath. or blurry vision.
HISTORY OF PAST ILLNESS SAME SYMPTOM BEFORE (-) DIABETES (-) HYPERTENSION (-) ASTHMA (-) KIDNEY DISEASE (-) Gastritis ( +) .
FAMILY HISTORY SAME DISEASE (-) HYPERTENSION (-) DIABETES (-) KIDNEY DISEASE (-) ASTHMA (-) .
Patient also consumed medications purchased from common stalls to relieve the headache. patients were has a history of drinking traditional herbal medicine for curing bodily pains once a week in two years Patient admits to be a hard coffee drinker Patient does not smoke or consume alcohol .Personal & Social History Patient often consumed spicy and sour food.
General condition General appearance • Moderately ill conciousness • Compos mentis Height • 168 cm Weight • 70 kg BMI • 24.8 .
VITAL SIGN BP: 120/80mmHg Temp: 36.2 °C Vital sign HR: 76times/minute RR 20 times/minute .
PHYSICAL EXAMINATION Head • Normocephaly • Conjunctiva anemic +/+ Eyes • Sclera icteric -/• Normotia • Secret -/Ears • Serumen -/• Septum deviation Nose • Secret -/• Concha normal Mouth • Oral mucous is anemic .
spider nevi (-) PALPATION • Ictus cordis is palpable at 5th ICS LMCS PERCUTION • Right heart border: ICS III-V LSD • Left heart border: ICS V 1cm medial LMCS • Upper heart border: ICS III LPSS AUSCULTATION • Regular I .THORAX INSPECTION • Ictus cordis is invisible.II absence of murmurs and gallop in heart’s sound .
ronchi (-/-).Thorax Lung Examination I : Symmetrical Pal : Equal vocal resonance Per : Sonor in both lungs A : Vesicular breath sound in both lung.wheezing (-/-) .
Abdominal Examination Inspection Brown skin. distended abdomen. icteric (-). venous hum (-) . caput meducae (-) Palpation Pain on palpation at Epigastric Liver not palpable Spleen not palpable Shifting dullness (-) Percussion No pain present on abdominal percussion Dullness CVA (-) Auscultation Bowel sound (+) 2 times/minute. Arterial bruit (-).
Extremity Examination • Warm acrals + + + + • Oedema - - .
200 700.6 (80 – 140) mg/dl (10 – 45) mg/dl (0.000 (37 – 48) % (5000 – 10000) /ul (150.4 – 1.3 Normal values (12 – 17) g% HT Leukocyte Trombocyte 14 14.LABoratory findings (05/03/2012) Test Hb Result 4.5) mg/dl .000) /ul RBG Ureum Creatinine 135 40 0.000 – 450.
March 5th 2012 Basophil Eosinophils Band Neutrophils Segmented Neutrophils Lymphocyte Monocyte Patient result 0 1 2 81 20 3 Normal range 0-1% 1-3% 2-6% 40-70% 20-40% 2-8% Reticulosyt MCV MCH MCHC RDW 2.0% .5-1.6-14.5% 82-91 cu µm 27-34Pg/cell 32-35 hb/cell 11.4 90 34 38 16 0.
anisopoikilositosis (ovalosit) • Leucocyte: increasing. trombosit cluster (+) • Impression: anemia normositer normocrom dd: infection . hypersegmentation • Trombocyte : increasing.Peripheral Blood Smear (sadt) • Eritrocyte : polikromasi.
200/ul • Ht:14% •Trombocyte:700.Pain on palpation at Epigastric • Hb: 4.4cu µm •MCHC : 38 hb/cell •RDW : 16 % •Peripheral blood smear (SADT) Impression: anemia normositer normokrom.51 years old.3 g% • leukocyte: 14. Signs Laboratory and others •Eyes : Conjungtiva anemic •Mouth : Oral mucous anemies •Abdomen: Inspection: distended (+) Palpation: .RESUME Symptoms ♂. black and bloody excreta since two days before hospital admittance Fatigue since two days before hospital admittance epigastric pain Nausea Vomiting Lost of appetite Headache consume traditional herbal medicine for curing bodily paiins once a week and analgetic drug for his headache in two years •history of gastritis (+) •patients often consumed spicy and sour-flavored food.000/ul •Segment : 81 % •Reticulocyte : 2. Dd: infection .
Differential diagnosis • Anemia gravis e. melena ec gastritis erosive • Anemia iron deficiency • Anemia gravis e.c duodenitis erosive • Anemia gravis ec esophageal varices • Anemia gravis e.c.c peptic ulcer .
c. gastritis erosive . Melena e.WORKING DIAGNOSIS Anemia Gravis e.c.
bilirubin ) Blood test (H. SGPT.pylori) Electrolyte level .glucose) Liver function (SGOT.Recommended examinations • • • • • • • • Endoscopy Serum Iron Total Iron Binding Capacity (TIBC) Erythrocyte sedimentation rate (LED) Urinalysis (protein.
9 % 20 tpm Kalnex 3 x 1 amp Omeprazole 1 x 1 amp Ceftriaxone 1 x 2 gr Ranitidin 2 x 1 amp PRC transfusion (6 packs) .Treatments • • • • • • IVFD NaCl 0.
prognosis Ad Vitam Dubia ad Bonam Ad Fungsionam dubia ad Bonam Ad sanationam dubia ad malam .