Morning Report

June 3th, 2021

 1. Pasien Laki-laki, Tn J, 68 th
Diagnosis Pemeriksaan Hasil pemeriksaan yang telah
Fisik dilakukan
•Melena ec Non Mata: conjungtiva anemis Hb 5,5
g/dl
Ur 69
mg/dl
Albu
min
3,2
g/dl
pH 7.50

Variceal Bleeding ec (+)

Leuko 16.60 Cr 1,0 Globul 1,5 PC 30,5
Gastropathy NSAID cyte 0 mg/dl in g/dl 02
Thorax: Auskultasi: ronki /mm3
basah halus nyaring di paru
•Moderate Anemia kanan setinggi ric III-IV
Platel 299.0 Na 138 SGO 9 PO 119
et 00 mmol/ T u/L 2
Normocytic sejajar linea parasternal /mm3 L
Normochrome ec Acute HT 18 K 4,5 m SGPT 10 SO 96
Bleeding Extremitas : mol/L U/L 2
Localization status Diff 0/0/84 Cl 110 H 24,
-Knee Dextra: Coun /9/7 mmol/ C0 3
•Bronchopneumonia L
swelling (+), Calor (-), t 3

(CAP)
Palor (-), Dolor (-), ROM MC 91 Ca 8,1 PT 9,5 BE 1,0
Limited V mg/dl s
•Osteoarthritis Genu
MC 28 APT 22,
Dextra -Knee Sinistra: H T 1s
Deformity(+) swelling (-), MCH 31 RB 119 INR 0,85
Calor (-), Palor (-), Dolor C G mg/dl
(-), ROM Limited
Hasil pemeriksaan yang telah dilakukan
Gambaran Darah Tepi EKG Ro Thorax PA
Terapi yang telah Terapi saat ini Tindakan yang akan
diberikan dilakukan
•Fasting for 8 hours •Rest/ Gastric Diet I • Tranfusi PRC 2 unit
(NGT Flow) •IVFD NaCl 0,9 % 8 • Esophagogastroduo
•Bolus lansoprazole 80 hours/kolf denoscopy
mg •Drip lansoprazole 30 mg in
100 cc NaCl 0,9 % 1
hours/kolf 4x20 mg iv
•Inj Ceftriaxon 2x1 gr iv
•Inj transamin 3x500 mg iv
•Inj vit k 3x10 mg iv
•Azithromycin 1x500 mg
po
•Succralfate 3 x 15 ml po
•N-Acethylsistein 3x200
mg po
•Paracetamol 3x500 mg po
 Jasrul 68 y.o, male, MW 02
• Cc:
 Black stool since 2 days ago.
• Present Illness History
 Black stool since 2 days ago. liquid consistency
 Right knee pain since 1 month ago, accompanied by swelling, not
accompanied by redness
 Pale since 1 week ago.
 Breathlessness  increased since 1 week ago, not affected by activity, ,
weather and food. 
 Fever since 1 week ago, not high, no sweating , no shivering
 Cough since 1 week ago with white phlegm, no blood
 History of bleeding: Skin bleeding/ bluish on the skin (-), nosebleed (-),
Gum bleeding (-), black vomit before (-),
 Micturition was normal 
• History of taking painkillers since 1 month
ago, he bought himself at the pharmacy
without a doctor's prescription.
• History of HT (-)
• History of DM (-)
 Physical Examination
• Consciousness level: CMC

• BP : 130/70  mmHg

• HR : 76 x/min

• RR :  22 x/minute

• T:  37 oC
• Skin : ptechiae (-) purpura (-) ekimosis (-)
• Eye
• Conjunctiva anemic  (+)
• Sclera  icteric (-)

• Neck
• JVP 5-2 cmH20
• Lymph Node: unpapble
• Lung: 
• Inspection:  symetric left=right
• Palpation: fremitus left=right
• Percussion:  sonor
• Auscultation: soft sonorous crackles in the right lung at the level of
ric III-IV parallel to the parasternal line, wheezing -/-
 COR

• Inspection: ictus is not seen.

• Palpation: ictus is palpated at 1 finger medial
LMCS ICS IV
• Percussion:
Left border: 1 finger medial LMCS ICS IV
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: reguler, murmur (-)
• Abdomen:
• Inspection: enlargement (-)
• Palpation: Hepar and lien unpalpable, epigastric
tenderness
• Percussion: tympani,
• Auscultation: bowel sound (+) normal
• Flank : knocking and pressure pain at CVA -/-
• Extremities:
• Localization status
• Knee Dextra: swelling (+), Calor (-), Palor (-), Dolor (-),
ROM Limited
• Knee Sinistra: Deformity(+) swelling (-), Calor (-),
Palor (-), Dolor (-), ROM Limited
• Physiologic Reflex +/+
• Pathologic Reflex -/-
 Laboratory
Hb 5,5 g/dl Ur 69 mg/dl Albumin 3,2 g/dl pH 7.50

Leukoc 16.600 Cr 1,0 mg/dl Globulin 1,5 g/dl PCO2 30,5

yte /mm3
Platelet 299.000 Na 138 SGOT 9 u/L PO2 119
/mm3 mmol/L

HT 18 K 4,5 mmol/L SGPT 10 U/L SO2 96

Diff 0/0/84/9/7 Cl 110 HCO3 24,3

Count mmol/L

MCV 91 Ca 8,1 mg/dl PT 9,5 s BEef 1,0

MCH 28 APTT 22,1 s

MCHC 31 RB 119 mg/dl INR 0,85

G
Ro Thorax
ECG
 Working Diagnose
•Melena ec Non Variceal Bleeding ec Gastropathy NSAID
•Moderate Anemia Normocytic Normochrome ec Acute
Bleeding
•Bronchopneumonia (CAP)
•Osteoarthritis Genu Dextra
 Differential Diagnose
• Melena ec Primary Portal
Hypertension
 Therapy
• Rest/ Fasting for 8 hours (NGT Flow) then Gastric Diet I/02 3L/i
• IVFD NaCl 0,9 % 8 hours/kolf
• Bolus lansoprazole 80 mg next drip lansoprazole 30 mg in 100 cc NaCl
0,9 % 1 hours/kolf 4x 20 mg iv
• Inj Ceftriaxon 2x1 gr iv
• Inj transamin 3x500 mg iv
• Inj vit k 3x10 mg iv
• Azitrhomycin 1x500 mg po
• Succralfate 3 x 15 ml po
• N-Acethylsistein 3x200 mg po
• Paracetamol 3x500 mg po
Plan
• PRC Tranfusion 2 unit
• Esophagogastroduodenoscopy