MORNING REPORT9th January 2015

IDENTITY

Name : IKDAge : 49 yoGender : maleEthnicity : BalineseReligion : HinduAddress : Br Kuwum Mambal

Desa Kuwum Marga TabananTime of admission : 14.45 WITA

AnamnesisCC: blacky stoolPresent history: Patient was complained his stool turned black

since 1 week before admission to hospital by his family members. Black stool was said to be less at the beginning but increases day by day. One day before admission to hospital, the frequency was 2 times a day and was about one to two glass on each defecation. Black stool was said to be accompanied with bad odour.

Cont...Present history: Patient was said to loss his appetite

to eat since one week before admission.

Patient also complained with weakness all over his body and was unable to carry out his daily activities.

Nausea and vomitting was denied Fever was denied Patient’s urination was said to be normal

3-4 times daily with volume of ¾ glass. Any changes in urine colour was denied.

Past and medical History:Patient was diagnosed with amnesia since 3 years ago.Patient also has history of anemia History of DM, HT, asthma, heart disease was denied.

Family History: None of family who had the same complaint.Family history of DM, HT, asthma, heart disease was denied.

Social and Daily habits: Alcohol consumption (-). Smoking (-) Drinking coffee (-)

Physical Examination

General appearance : moderate illLevel of consciousness/GCS : CM: E4V5M6Vital Sign:

•BP: 130/80 mmHg•RR: 20x/min•PR: 80 x/min•tax : 36,2 °C•BW : 70 kg•Height : 170 cm•BMI : 24,2 kg/m2 (pre-obesity)

Eyes : anemis (+/+); icterus (-/-); pupillary reaction +/+ isocoric; palpebral edema -/-,

THT : tonsils T1/T1; pharyngeal hyperemia (-); tongue normal Neck : JVP RP + 0 cmH2O; lymph node enlargement (-).Thorax : Simetric, retraction (-),

Cor : inspection : ictus cordis unseen palpation : IC unpalpable percution : UB ICS II, RB : PSL D, LB : 1 cm MCL S auscultation : S1S2 single regular murmur (-)

Pul : inspection : simetric palpation :VF N/N percution : sonor/sonor auscultation : vesicular +/+; ronchi -/-, wheezing -/-

Abdomen : inspection : Distensi (-), auscultation : bowel sound (+)

increasedpercussion : thymphanipalpation : Liver & spleen was

unpalpable, epigastrial pain (+)

RT : anus sphincter tone (+), no mass, blackish stool (+)

Extremities: warm +/+; edema -/- +/+ -/-

Laboratory ExaminationsCOMPLETE BLOOD COUNTParameter Result Unit Remark Reference

rangeWBC 9,22 103/μL 4,1 – 11,0 -Ne 6,4 69,5

%103/μL 2,5 – 7,5

-Ly 2,15 23,3% 103/μL 1,0 – 4,0-Mo 0,578 6,2% 103/μL 0,1 – 1,2-Eo 0,012 0,128

%103/μL 0,0 – 0,5

-Ba 0,078 0,845%

103/μL 0,0 – 0,1

RBC 1,45 106/μL low 4,0 – 5,2HGB 2,3 g/dL low 12,00 – 16,00HCT 10,7 % low 36,0 - 46,0MCV 80,6 fL 80,0 – 100,0MCH 26,0 pg 26,0 – 34,0MCHC 32,3 g/dL 31,0 – 36,0PLT 204 103/μL 150 – 440

clinical chemistryParameter Result Unit Remarks Normal Range

Alkali Phosphatse (ALP) 136 Mg/dl H 53 – 128

Bilirubin Total 0,26 Mg/dl L 0,30 – 1,30

Bilirubin Direk 0,2 Mg/dl 0.00 – 0,30

Bilirubin Indirek 0,06 Mg/dl 0,00 – 0,80

SGOT 15,8 U/L 11,00 – 33,00

SGPT 13,6 U/L 11,00 – 50,00

Total Protein 6,34 g/dl L 6,40 – 8,30

Albumin 3,62 g/dl 3,40 – 4,80

Globulin 2,72 g/dl L 3,2 – 3,7

Gamma GT 71 U/L H 11,00 – 49.00

BUN 11 Mg/dl 8,00 – 23,00

Creatinin 1,17 Mg/dl 0,70 – 1,20

Random Blood Glucose 84 Mg/dl 70,00 – 140,00

Natrium 143,00 Mmol/L 136,00 – 145,00

Kalium 3,79 mmol./L 3,50 – 5,10

ECG Result Sinus Rhythm HR 102x/minute Normal axis Normal p waves PR interval 0,12 s Normal QRS No ST & T changesConclusion :sinus tachycardia

Cor:CTR 48% Pulmo: nodul(-),

infiltrat (-), broncovaskular pattern normal

Left and right sinus pleura are sharp

Left and right diafragma is normal

Conclusion: cor&pulmo normal

Chest X-Ray

BOF No radioopaque

appearance Gas distribution

increased mixed with fecal material

No enlargement of liver and spleen

Conclussion: no visible opaque stone along urinary tract, increase of bowel gas

Assessment Obs Melena e.c suspect peptic ulcer

Severe anemia hypochromic micrositer ec iron deficiency anemia + bleeding

PlanningTherapy Hospitalized IVFD NaCl 0,9% 20 dpm Fasting NGT+GCblood (+) Pantoprazole 2x40mg IV Antacid syr 3x C1 Sucralfat syr 3x CI Tranfusion PRC until hb > 8 g/dl

Planing diagnosis EGD + biopsi CBC post transfusion Psychiatry consultation

Monitoring

Vital signs Complaint Feses Water Balance CBC

THANK YOU