DUTY REPORT


November 14th ,2017

dr. Rudi Erwin

 Emon Chendra, Male, 29yo, MW10

 Cc:

 Black stool since 2 weeks ago.

 Present Illness History

 Black stool since 2 weeks ago. Frequency 2-3x/days. Liquid and black
like asphalt.
 Epigastric pain since 2 weeks ago.
 Nausea without vomite since 1 weekago.
 Decreased of appatite (+)
 Patient often eat late since 1 year ago.
 No fever
 No cough
 Micturation was normal
 
Past Illness History
• History of dyspepsia syndrome (+) since 1 year ago

Family Illness History

• Nothing family with the same disease
 Physical Examination

 Consciousness level : CMC

 BP : 120/70 mmHg

 HR : 94x/minute

 RR : 20 x/minute

 T: 36,5 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: sonor
 Auscultation: vesicular, rales -/-, 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,
epigastric tenderness (+)
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Oedem -/-
 Physiologic reflex +/+
 Patologic reflex -/-
 Laboratory

Hb
Ht
 4,8 gr/dl
20%
WBC 6.680/mm3
Platelet 447.000/mm3
MCV/MCH/MCHC 51/12/24
Ur/Cr 14/1,1
Na/K/Cl/Ca 139/4,5/109/8,5
RBG 96 mg/dl
PT/aPTT 11,4/41,0

 Working Diagnosis

 Melena cb Peptic ulcer
 Severe anemia microcytic hypochrome cb
chronic bleeding

Dd/
 Melena ec Gastropathy erosiva
 Severe anemia microcytic hypochrome cb
chronic disease
 Therapy

 Rest/ NGT flow fasting 8 h  Gastric diet I
 Bolus lansoprazole 60mg (IV)
 Drip lansoprazole 60mg in 500cc NacL 0,9% finished
10 hours
 Domperidon tab 3x10 mg (po)
 Sucralfat syr 3xcth II (po)
 Planning

 Esophagogastroduodenoscopy