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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