MEDICAL CONSULTATION

From Anaestes Department

Patient with:
1. Respiratory Failure type 2
2. Septic Condition dt Pneumonia

3. Anemia Normochromic Normocytic dt Blood Loss

The aim of consultation:

Management of Hematemesis and Melena
 Summary of Database
Mr. S/ 38 y.o/ Ward ICU
Alloanamnesis
Chief Complaint: Black tarry stool
History of Present Illness:
Patient was reffered from RS Mbening Blitar with diagnosed mild head injury, Subarachnoid bleeding
and Dislocation of vertebrae cervical. She got accident, fallen from the building, with height was about 7-8
meters. After he fall, he got uncosciousnes conditon for 1-2 hours. After he gain his conciousnes, he forget
about the accident. He was hospitalized in RSSA and got surgery therapy from ortopaedic departement,
after thar he was transferred to the ICU at 11/02/2021.
Last night Anaestesiolgy department reported that the patient got red darked vomite from nasogastric
tube and black tarry stool since 2 days ago. The volume of black tarry stool was about 900 cc in 21/2/2021
and 750 cc in 22/2/2021. Before last night, patient never had complaint about red darked vomit and black
tarry stool. Patient got fever since 3 days ago, when he hospitalized in ICU room.
He never had history about hypertension and DM mellitus before. He also didn’t consumed alcohol.
He also didn’t have history of jaundice and liver disease before. He also didn’t consumed “jamu” and
painkiller drug before
 Summary of Database
Past Medical History:
Patient was reffered from RS Mbening Blitar, after got accident fall from bulding with height
about 7-8 mters

Family History:
- Her father got high blood pressure, and died 7 years ago.
- There’s no history viral infection ( hepatitis ) in her family.

Social History:
He worked as a laborer at traditional market. He was married with one wife and had 2 children

Review of System:
Decreased of body weight (-)
Bleeding (-)
Urination was normal
 Physical Examination
General appearance Severely ill Sat O2 99% on mechanical ventilator
GCS 4x1 (on tracheostomy and mechanical ventilator)
BW 45 kg, H: 150 cm
BMI : 20.0 kg/m2
BP 106/57 mmHg PR 104 bpm regular strong RR 25 tpm Tax 38.5 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), applied nasogastric tube with red darked residu (volume
±200cc)
Neck JVP R+ 2 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular
+ |- -|-
Sonor | Sonor Vesicular | Vesicular
+| - - |-
Cardio Ictus invisible, palpable at lateral MCL (S) ICS V
LHM ~ ictus, RHM ~ SL S1 S2 single, regular,
Murmur (-), thrill (-), gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium pain (+)
Lien/ Traube space tympany
Extremities Edema (-), pale (+), MMT 5 | 5 , Pathologic Reflex (-); Lateralization
5|5
RT and Genitourinary Tonus sphincter ani (+); colon mucous slippery; melena (+); hematoschezia (-)
UOP = 1200 cc/24 hours Urine colour yellow
 Laboratory Findings (22/02/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 23.840 /uL 4.700 – 11.300 /µL Ureum 68,7 mg/dL 20-40 mg/dL

Hemoglobine 6,2 g/dL 11,4 - 15,1 g/dl Creatinine 0,82 mg/dL <1,2 mg/dL

PCV 18,9 % 38 - 42% Natrium 136 mmol/L 136-145 mmol/L

Thrombocyte 307.000/uL 142.000 – 424.000 /µL Kalium 3,23 3,5-5,0 mmol/L

mmol/L
MCV 88,6 fl 80-93 fl Chlorida 101 mmol/L 98-106 mmol/L

MCH 29,7,8 pg 27-31 pg RBS 179 mg/dL < 200 mg/dl

Eo/Bas/Neu/ 0,3/0/54,9/30, 0-4/0-1/51-67/ PPT 12,7 detik 9.3-11.4 detik

Limf/Mon 3/14,5 25-33/2-5
APTT 22,8 detik 24.8-34.4
SGOT 114 U/L 0-40 U/L INR 1.24 0.8-1.30

SGPT 46 U/L 0-41 U/L E Gfr 113,178 ml/min/1.73 m2

ml/min/1.73
m2

Albumin 2,43 g/dL 3.5-5.5 g/dL

Electrocardiography (22/02/2021)
 Electrocardiography (22/02/2021)
• Sinus tachycardia, HR 108 bpm regular
• Frontal Axis : Normal
• Horizontal Axis : Normal
• P wave : 0,08 s
• PR interval : 0,20 s
• QRS complex : 0,08 s
• QT interval : 0,38 s
• ST segment : Isoelectric

Conclusion : Sinus tachycardia , HR 108 bpm

Chest X-Ray (22/02/2021)
 Chest X-Ray (17/02/21)
• AP position, symmetric, enough KV, less inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo : bronchovascular was increased in lung dextra
• Cor: site N, size CTR 55%, shape N, elongation aorta (-),
dilatation aorta (-) cardiac waist (+)

Conclusion: Pneumonia
 Age 38 yo = 0
Shock , No. =1
Comorbidity
pneumonia= 2
Diagnosis =0
Evidence of bleeding
=2

Total score =
5
 • BUN 32,1 mg/dL
• Hb 6,2 g/dL
• BP 106/57 mmHg
• Melena (+)

Total Score 14
qSOFA

JAMA. 2019
SOFA Score

JAMA. 2019
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 1. Respiratory Non pharmacology P.Mo:
Failure Type 2 - Bed rest, semi fowler Subj,
Subjective dt CF lateral position VS,GCS
- Decrease of consciousness servical 4-5 - O2 suplementation qSOFA,
- Shortness of breath Asia B with mechanical SOFA score,
Objective ventilation UOP , Ur/Cr
RR: 24x/m on mechanical - NGT insertion  Fluid
ventilation diet 6x200 cc P.Ed:
SpO2: 98 % on mechanical - Catheter Insertion Worsening
ventilation condition,
Tho: Coarse rhonkhi at medio Planning
basal lung dextra Pharmacology
- Treat underlying causes therapy
Laboratory Prognosis
Leucocyte: 23.840
T: 38,8C
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 2. Septic 2.1 Pneumonia Blood and Non pharmacology PMo:
shock CAP sputum - Bed rest, semi fowler S, VS, VAS
Subjective base position score, CBC
- Decrease of 2.2 Ventilator culture and - O2 Suplementation per 3 days,
consciousness induced antibiotic - NGT insertion remeasure
- Shortness of breath Pneumonia sensitivity - Catheter Insertion lactic acid,
UOP
Objective Pharmacology
GCS 4x1 ; BP 106/57 mmHg - IVFD NS 50 cc/hours PEd:
RR 24 tpm; SpO2: 99% on - IV. Levofloxacine 1x750 adequate
mechanical ventilator mg antibiotic,
SOFA 10 - IV. Amikacyn 1x 1 gr About risk
- PO NAC 3x200mg factors,
Laboratory - Nebulizer Ventolin 1 therapy,
Leukosit 23.840/uL resp/8 hours

CXR
Pneumonia
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 3. Upper GI 3.1 Peptic Endoscopy Non pharmacology Pmo :
Bleeding Ulcer Bleeding when - Bedrest S, VS, Sign
Subjective patient in - O2 nasal canule 4 lpm of bleeding,
- Hematemesis (+), stable - IVFD NS 500cc / 24 hours Gastric
Melena (+) 3.3 SRMD condition - Fasting Lavage
- Never consumed herbal - NGT Insertion
potion, pain killer drugs - GC 1x clear, start liquid Ped :
nor alcohol cold diet (sugar water) -Educate to
6x200cc. fasting until
Objective the NGT
H/NConjungtiva Anemia (+) Pharmacology clear, and
RT : Melena (+) - Intravenous Bolus possible
Lansoprazole 60 mg cause of
Laboratory continue with drip the disease
Hb : 6,2 lansoprazole 6mg/hour - Educated
MCV/MCH : 88,7/29,8 (stop if GC clear, and the patient
switch to 1x30 mg) continuous
Rockal Score 3 - Intravenous the PPI until
Glasgow Blatchford Bleeding Metoclopramide 3x10 mg 5-7 weeks.
Score : 15 (prn)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 4. Increase of 6.1 Septic HbSag, Anti treat underlying disease Pmo:
Transaminase MODS HCV OT PT,
Subjective
- Decrease of 6.2 Viral Hep Ped :
consciousness Infection Educate the
- Productive cough 1 patient about
week the likelines
of the
- Shortness of breath abnormality
of liver
Objective function
GCS 335 ; BP 106/57
RR 29 tpm; SpO2: 99%
NRBM
qSOFA 2 SOFA 4

Laboratory
Leukosit 12.020/uL
OT/PT 114/61
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 5. Anemia 3.1 Acute - Reticulocyte Non pharmacology Pmo :
Normochrom Blood Loss - Blood Smear - O2 suplementation S, VS, Sign
Subjective Normocytic of bleeding,
Black tarry stool (+), red Pharmacology sign of
darken vomit liquid - Transfussion PRC 2 oxygen
pack/day Target Hb hunger,
Objective >7 g/dL transfussio
Conj. Anemia (+), Residue n reaction
NGT was red darken color ( TRALI,
RT (+) melena TACO)

Laboratory Ped :
Hb : 6,2 Educate
MCV/MCH : 88,7/29,8 about
possibility
cause of
disease
Transfussio
n reaction
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 6. Pneumonia 6.1 Atypical Blood and Non pharmacology Pmo :
Sputum - Bed rest, semi fowler S, VS, sign
Subjective 6.2 Bacterial base culture position of bleeding
- Fever 4 days ago and - O2 Suplementation
- Shortness of breath 6.3 Induced sensitivity - NGT insertion Ped :
by test of - Catheter Insertion Educate
Objective mechanical antibiotics about
RR: 24x/m on mechanical ventilator Pharmacology possibility
ventilation - IVFD NS 50 cc/hours cause of
SpO2: 98 % on mechanical - IV. Levofloxacine 1x750 disease
ventilation mg
Tho: Coarse rhonkhi at - IV. Amikacyn 1x 1 gr
medio basal lung dextra - PO NAC 3x200mg
- Nebulizer Ventolin 1
Laboratory resp/8 hours
Leucocyte: 23.840
T: 38,8C
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 6. Moderate 6.1 Low Intake - Treat underlying disease Pmo :
Hypoalbuminemia this patient S, VS, sign
Subjective 6.2 of bleeding
Melena (+) Hypercatabolic
state Ped :
Objective Educate
RT : Melena (+) about
possibility
Laboratory cause of
Alb: 2,43 g/dL disease
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 52 yo/ Brantas ward 6. Mild 9.1 Low Intake Non Pharmacology: Pmo :
Hypokalemia (-) S, VS
Subjective
(-) Pharmacology: Ped :
Per NGT KSR 2x5 gr Educate
Objective about
(-) possibility
cause of
Laboratory disease
K: 3,23
 TREATMENT GIVEN
BY ANAESTESIOLOGY DEPARTMENT
Non pharmacology :
- IVFD NS 50 cc/jam
- Transfussion of PRC 2 pack/day target
Hb >10 g/dL
- Mechanical ventilator with setting
(PC-SIMV, PEEP 7, Frequency 24x/m,
P control 24 and FiO2 60%
Pharmacology :
- IV Amikacyn 1x1 gr
- IV Ranitidin 2x50 mg
- IV Metoclopramide 3x10 mg
- IV Drip NE 0,05 mcg/kgBB/minute, up
titration until MAP > 65
- IV Paracetamol 3x1 gr
- IV Ceftriaxone 2x1gr
- IV Drip Lansoprazole 6 mg/hours
- Per NGT NAC 3x200mg
- Per NGT Sucralfat syr 3x1cth
- Per NGT Lactulosa syr 3x1 cth
- Tranfusion of Albumin 20% 100 cc/day,
target Albumin was 2,5 gr/dL
 We suggest this patient

- Patient on Fasting, NGT insertion -> Gastric

Lavage/8Hr -> clear -> start 6x200cc liquid diet
- IV Lansoprazole 1x30mg (first GC clear brownish)
- Transfusion of PRC 2 bag / day to Hb > 8gr/dL
- HbsAg and Anti HCV examination to rule out
Hepatitis Viral Infection
- Endoscopy if the patient’s condition is stable

The patient will be joined care with the

Gastrohepatology division
 Problem Analysis

DOC Pneumonia

Septic Conditon Viral Hepatitis

Infection

Increase of
transaminase
Melena
Acute blood
loss

Anemia NN

NSAID
Consumption
(chronic)
 CONDITION THIS MORNING

GCS : 4x1
BP : 112/98 mmHg
HR : 88 bpm
RR : 22 tpm
Tax : 36.5 C
RBS : 88 mg/dL (05.00)
Thank You