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DEPARTEMENT OF
INTERNISTEmergency care unit, jan 10
(02.00 pm- 07.00 am)
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Name : Mr. Ngalim Age : 51 YO
Address : Kedungdadi Sugio
Lamongan Work : Private worker
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ANAMNESIS
Chief complaint: black stool History of present illnes:Patient complaint
he had black stool as petis since 5 days
before hospitalized. Defecation 3 times a day
with abdominal pain especially in umbilical
area. Pain continuesly. Nause and vomitting
since 5 days before hospitalized. Vomit 2-3
times a day, color black, mixed food. After allhe got headache and body weakness.
Yesterday (1 day before hospitalized) he
brought to Blawi Polyclinic and he didntt feel
better.
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History or pass illnes:- History of DM (3 years) , HT (-),
History of family:
- denied
History of sociality:- Smooking , drinking coffee, traditional medicine
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Physical
examination:
General status GCS : 456
Vital Sign:
BP : 90/47mmHg Pulse : 104/mnt
Temp : 36,70C
RR : 20/mnt
Head/neck
An+, ict- cyan-, dys -
JVP normal
Thoraks
Symmetric, retraction (-
)Cor : S1 S2 single,
murmur (-), gallop (-)
Pulmo: ves/ves, rh -/-,
wh -/-Abdomen
Supple, right lower
abdominal pain (less),
thimpany, bowel sound(+) N,
Extremity
cool, wet, oedema -,
eritema palmaris -,
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Laboratory
Findings Diff count: 1/0/78/16/5
Hematocrite: 15,9 %
Hb 5,3 mg/dl LED 89/119
Leukocytes : 12.900
Thrombocyte : 228.000
Albumin 2,8
Globulin 2,1
Total protein 4,9
Alkali fosfatse 168
SGOT 10 U/L
SGPT 13 U/L
Clorida serum 105Kalium serum 5,3
Natrium serum 133
Creatinin serum : 1,8
mg/dl
Urea 188
Uric Acid : 6,8 mg/dl
GDA : 229
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CLUE AND CUE
Extremitycool, wet, pale, oedema
-, eritema palmaris -
Hb 5,3 mg/dl
Leukocytes : 12.900
Natrium serum 133
GDA : 229
Male, 51 yr Abdominal pain
Melena
Nausea & Vomit Headache
Fatigue
Hypotension
(90/47mmHg)
Tachicardia (104/m)
Abdomen
Supple, right lowerabdominal pain (less),
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RESUME
Patient, Male 51 YO, with black stool andabdominal pain 5 days before hospitalized. He
felt fatigue and headache then. Drinking
traditional medicine jamu even 8 times a day.
BP : 90/47mmHg, Pulse : 104/mnt, anemis
+, right lower kuadran abdominal pain (mild),
extremity cool, wet, pale
Hb 5,3 mg/dl Leukocytes : 12.900
Sodium 133
Random Blood Sugar : 229
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Problem List:
-Acute Abdominal Pain-Hypovolemic Shock
-Hyperglicemia
-Anemia
Initial Diagnosis
Haematemesis Melenae.c Acute Gastritis Erosiva
Hypovolemik Shock
DM type 2
PlanningDiagnosis
DL, RFT, LFT,
HbA1c
EndoscopyUSG Abdomen
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Planning Therapy
O2 nasal 3lpm
IVFD Asering loading 2000cc (20-40ml/kgBB)
NGT
DC
Ranitidin IV 2x50mgMetamizole 3x500mg
Pantoprazole bolus 2x 40 mg 8mg/hour (syringe
pump 4 amp/24 hours)
Tranexamic Acid 2x250mgTransfussion (PRC)
RCI 4U
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MONITORING
Vital signs Urinase
Complaint
Hb, Electrolite serum
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PROGNOSIS
Dubia ad bonam
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