Summary of Database

Mrs. C/ 79 yo/ Ward INCOVIT

Heteroanamnesa
Chief Complaint: Coffe ground vomiting
History of Present Illness:
The patient complains of bloody and coffe ground vomiting since this
morning for about 100 cc. The vomit occur suddenly after she drank. She also
complaints about weakness in all of his body the body since one month ago,
accompanied by decrease of appetite. She feel pain in the pit of his stomach and
nausea.
She has history of the same complaint, similar complaint 2 weeks ago, and
hospitalized at private hospital, received treatment and transfusion, then the
patient was discharge then referred to the gastroenterohepatology clinic in RSSA
for endoscopy. History of hepatitis, yellowish and abdominal pain before
was dineid
 Summary of Database
Past Medical History:
History of chief complain (+), 2 weeks ago
History of hepatitis, “sakit kuning”, abdominal pain was denied.

Family History:
There is no remarkable history of her family

Social History:
She lives with her third daughter. The patient has not been doing routine activities since 2
weeks ago. Patients usually consume marrow porridge daily 3 times a day.

Review of System:
Urination was normal and defecation is hard
 Physical Examination
General appearance Look Moderately ill Sat O2 99% on NC 3 lpm
GCS 456 BMI 19,3 kg/m2
BP 150/100 mmHg PR 116 bpm regular strong RR 20 tpm T 36,3 oC
Head Not performed
Neck Not performed

Chest Not performed

Lung Not performed

Cardio Not performed

Abdomen Not performed

Extremities Not performed

 Laboratory Findings (15/03/22)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 5,660 4.700 – 11.300 /µL Ureum 20-40 mg/dL

Hemoglobine 12.1 11,4 - 15,1 g/dl Creatinine <1,2 mg/dL

PCV 38.90 38 - 42%

Thrombocyte 226,000 142.000 – 424.000 /µL Natrium 136-145 mmol/L

MCV 90,30 80-93 fl Kalium 3,5-5,0 mmol/L

MCH 28,80 27-31 pg Chlorida 98-106 mmol/L

Eo/Bas/Neu/ 2,7/0,3/84,7/ HBsAg HBsAg

Limf/Mon 7,4/4,9 0.4/ 0.2/ 64.4/ 21.6/ 13.4
Anti-HCV Anti-HCV
SGOT 0-40 U/L PPT 16.70 (11.7) 9,4-11,3

SGPT 0-41 U/L APTT 30.60 (25.0) 24,6-30,6

Albumin 3.5-5.5 g/dL Swab Antigen Negative

SARS COV-2
Bilirubin total <1.0 mg/dl

Bilirubin direct <0.25 mg/dl

Bilirubin indirect <0.75 mg/dl

Chest X-Ray (15/03/2022)
 Chest X-Ray (15/03/2022)
• AP position, symmetric, enough KV, enough inspiration
• Trachea was in the middle
• Soft tissue and bone look normal
• Right diaphragma was covered by opacity, Left diaphragma was
dome shape
• Right costophrenico angle was covered by opacity, left was
sharp
• Pulmo : infiltrate with a fibrotic component appears in the upper
middle field of the left lung
• Cor : site N, shape N, cardiac waist +, CTR 50%
Conclusion:
• Pneumonia with aortic sclerosis