1

Aidil Saputra/ male/ 20 yo/ MW 11

Chief complain : Bloody vomit since 2 days ago

Present illness history :

• Bloody vomit since 2 days ago, the amount of a quarter cup, twice the
frequency. Previously the patient had been vomiting since 10 days ago.
• decreased appetite since 10 days ago
• Shortness of breath since 1 days ago, shortness of breath not affected by
activity, weather, or food
• Fever since 3 days ago, continuously, not shivering and not sweating
profusely
• Cough since 3 days ago, cough with phlegm, not mixed with blood
• weight loss since illness
• Mixturition is normal limit
• Defecation is normal limit, black stool (-)
- referral patients from regional hospitals for further management
- There is no history of taking anti-pain medication
- There is no history of drinking herbal medicine
Past illness history

• History of hypertension (-)

• History of DM (-)

Family illness history

• Unremarkable family history

Physical Examination
VII

• General Appearance : Severe

• Consciousness level: compos mentis cooperative

• BP : 120/70 mmHg

• HR : 100 x/minute

• RR : 23 x/minute

• T : 37,5 º C

• SpO2 : 99%
• Eye
– conjunctiva anemic (-) VII
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: normochest, symmetric right=left
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: Bronchovesicular, Rh +/+, Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: distension (-)
– Palpation: supel, liver and spleen not palpable
– Percussion : tympani (+)
– Auscultation: bowel sound (+) normal

• Extremities:
– Oedema -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 17,1 g/dL
Ht 43
WBC 32.030 /mm3
Platelet 330.000 mm3
Diff. Count 0/0/89/3/8
PT/APTT 10,9/24,8

Ur/Cr 105/1,6 g/dL

Alb/glob 4,3/3,2 g/dL

SGOT/SGPT 17/7 U/L
Na/K/Cl 105/3,9/63 g/dL
GDS 103 mg/dL
Chest X-Ray VII
ECG
VII
Working Diagnosis

• Haematemesis cb suspect mallory weiss

• Community Acquired Pneumonia
• Severe hyponatremia cb gastrointestinal loss
• Acute kidney injury cb pere renal cb dehydration
Therapy

• Rest / open NGT  fasting 8 hours  liquid diet 6 x 250 cc via NGT /O2 3
LPM via Nasal Canul
• IVFD Nacl O,9% 8hour/kolf
• IVFD Nacl 3 % 24 hours/kolf (3 kolf)
• Bolus lansoprazol 60 mg iv  lansoprazol 4 x 30 mg iv
• Tranexamad acid 3 x 500 mg iv
• Vitamin K 3 x 10 mg iv
• Parasetamol 3 x 500 mg po
• N acetylsistein 3 x 200 mg po
• Domperidon 3 x 10 mg po
• Sukralfat syrup 3 x 10 mg po
Plan

• Sputum culture