25th July 2011

Name Age Sex Address Ethnicity Religion No. RM Time of admission Date of admission

:K : 69 years old : Female : Jl Tunjung Gg 1 No. 5, Dps : Balinese : Hindu : 01.48.38.94 : 1400 : 25th July 2011

Chief complain: Bloody vomit Present History: Patient was presented at the emergency department complaining of bloody vomit since 2 days ago. She vomitted blood 2x on Saturday and once on Monday morning. It happened suddenly. The bloody vomit was blackish red in colour. The volume was around 50cc. There was no residual of meal in it.

Patient also complained of nausea since 2 weeks ago. She vomits each time after consuming meals. She had lost 5 kg in the last 2 months. Urination was normal Tea-coloured urine (-) Epigastrial pain (-)

Past history: Patient complained of fluid in stomach a month ago. She had undergone abdominal USG and endoscopy and was diagnosed with Hepatitis C and liver cirrhosis. History of heart disease and kidney disease was denied. Family history No illnesses run in his family that are relevant to his presentation.

Drugs history Spironalacton 100mg 2x1 Ursodeoxycholic Acid 250mg 2x1 Propanolol 10mg 2x1 Social history No history of alcohol consumption and smoking. No use of recreational drugs. She had not received any blood transfusion before.

General appearance: Moderate BP: 100/70 mmHg, supine position PR: 50x/min, regular, strong RR: 20x/min, regular Tax: 36.3o C BW: 30kg BH: 150cm BMI: 13.33kg/m2

Eyes : anemic +/+, konjuntiva pallor -/-, iketerus -/-, scratch marks (-) ENT : Gum bleeding (-) Neck : JVP 0 cm H2O, lymph enlargement (-) Thorax : Heart : Insp : ictus cordis not visible, scratch marks (-), bruising (-), hair loss (-) Palp : ictus cordis palpable ICS V MCL Perc : UB: ICS II, RB: PSL D, LB: ICS V MCL Ausc : S1S2 single regular murmur (-) Lungs : Insp : symmetrical movement Palp : tactile fremitus N/N Perc : Sonor/sonor Ausc : Vesicular +/+, rh -/-, wh-/-

Abdomen : Insp : Distention (+), flank bulging symmetrical, collateral veins distension, bruising (-), scratch Ausc Perc Palp marks (-) : bowel sounds (+) normal, Bruits (-) : Shifting dullnes (-) : Fluid thrill (+), tenderness (-), rebound tenderness (-), liver and spleen are not palpable, no costovertebral angle tenderness

Extremities : warm, pitting edema -+/-+, RT : Anus sphincter tone (+), blackish stool (+), pain (-), fresh blood (-), mucus (-)

Parameter WBC -Ne -Ly -Mo -Eo -Ba RBC HGB HCT MCV MCH MCHC RDW PLT MPV 2.08 0.72 0.00 0.08

Result 15.40 (H) 12.50 (H) 81.20% 13.50% 4.69% 0.00% 0.54% 2.64 9.00 (L) 25.40 (L) 96.00 34.10 35.50 13.50 143.00 7.70

Unit 103/L 103/L 103/L 103/L 103/L 103/L 106/L g/dL % fL pg g/dL % 103/L fL

Reference range 4,1 11,0 2,5 7,5 1,0 4,0 0,1 1,2 0,0 0,5 0,0 0,1 4,00 5,20 12,00 16,00 36,0 46,0 80,0 100,0 26,0 34,0 31,0 36,0 11,0 14,8 40 440 6,80 10,0

Parameter Bilirubin total Bilirubin indirect Bilirubin Direct Alkali phosphatase SGOT SGPT Gamma GT Total protein Albumin Globulin BUN Creatinine Ureum

Result 2.79 0.51 2.28 79.00 111.90 46.00 138.00 6.44 2.53 3.91 37.00 1.11 80.20

Unit mg/dl mg/dl mg/dL U/dL U/dL U/dL U/dL g/L g/dl g/dl mg/dl mg/dl mg/dl

Reference range 0,00-1,30 <0.80 0,00-0,30 53,00-128,00 11,00-33,00 11,00-50,00 11,00-49,00 6,40-8,30 3,40-4,80 3.20-3.70 10,00-23,00 0,50-1,20 0.00-0.00

Interpretation H H H

H H H

L H H H H

Parameter

Result

Unit

Reference range

Interpretation

pH PCO2 PO2 Hct HCO3TCO2 BE(B) SO2c THbc Natrium Kalium

7.509 28.30 171.70 27.00 22.00 22.90 -0.50 99.30 9.10 109.00 5.37

mmHg mmHg % mmol/L mmol/L mmol/L % g/dL mmol/L mmol/L

7.35- 7.45 35.00- 45.00 80.00- 100.00 37.00-48.00 22.0-26.0 24.00-30.00 -2-2 13.00-18.00 136.00-145.00 3.50-5.10

H L H L N L N N L L H

Rhythm: sinus Axis: Normal Heart rate: 51x/minute ST: normal T waves: Normal Conclusion: Sinus bradycardia

Hematemesis Melena ec susp Rupture Varices Esophagus Hipovolemic Shock Mild Anemia Nomochromic Normositer ec acute bleeding Liver Cirrhosis Hepatitis C Hiponatremia (109) Chronic Asympthomatic Hipoosmolar Hipovolemic

Hospital admisssion IVFD NaCl 0.9% 30 drips/minute IVFD HaES steril 20 drips/minute NGT Antacida 3xCI Sucralfat 3xCI Pantoprazole 2x40mg IV Tranexamat Acid 3xCI Lactulose 3xCI Sandostatin 2 ampul in 250cc 20 drips/minute @ 8 hours PRC tranfusion until Hb >10

Planning: Repeat EGD Check old medical record Repeat CBC after blood trasfusion

Monitoring: -Vital signs -Complaints -Water balance