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Physical examination
BP = 70/palp (ER) 130/80 mmHg (W) PR = 105 bpm (ER) RR = 24 tpm GCS 456 Catharact S, pupil D light reflex + NGT - hematemesis Tax : 36.5 C General appearance looked severely ill Head Neck Chest Heart: Pale conjunctiva + JVP R + 2 cmH2O Ictus invisible and palpable at 2m lat MCL ICS V Sinistra LHM ictus, heart waist + RHM: SL Dextra S1, S2 single with no murmur SF D = S, s s v v s s vv s s vv Rh - --Wh - ---
Lung:
liver span 10cm,troube space tympani, bowel sound (+) increase RT melena +, Catheter urine inserted urine production 200cc/1hour
Extremities
Value 135 4.37 103 136-145 mmol / L 3,5-5,0 mmol / L 98-106 mmol / L
Lab Urinalysis SG PH Leucocyte Nitrite Protein Glucose Erythrocyte Keton urine Urobilinogen Bilirubin
1.015 6 3+ 2+ 5+
Value
Value
+ -
Eritrosit
2+ -
4-6 20-25 + +
ECG (6/7/2011)
Sinus rhythm, heart rate 94 bpm Frontal Axis : normal Horizontal Axis : normal PR interval : 0.14 QRS complex : 0.04 QT interval : 0.34 PVC occasional Conclusion : sinus rhythm HR 94 bpm
CXR (3/07/2011)
AP position, asymmetric, enough KV , less Inspiration Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are sharp Right and left hemidiaphragm are dome-shape Pulmo : looks normal Cor : CTR 63%, heart waist +, conus pulmonalis prominent, calcification of the aorta Conclusion: cardiomegaly, calcification of the aorta
PL
IDx
PDx
PTx
PMo
Male/59yo GCS 456 Cold acral BP 70/palp PR 105tpm RR24tpm Urine production 200cc/hour
Male/59yo Hematemesis Melena Post shock hypoglycemia RT Melena + Anemia N-N Hb 9.0 g/dl MCV/MCH 84/29.2
1. Shock condition
CVP
O2 8-10lpm NRBM Insert NGT Insert catheter NS 0.9% 250cc Rehydration 1000cc/hour IVFD NS 0.9% 20tpm
2. 2.1 Peptic Hematemesis Ulcer Disease Melena 2.1.1 due to NSAID Gastropathy
endoscopy O2 8-10lpm NRBM IVFD NS 0.9% 20tpm Insert NGT gastric lavage/8 hours If clear start diet 6x200cc Inj Omeprazole 1x40mg iv the drip Omeprazole 8mg/hour
Male/59yo 4. HF stage C Hypertension st II FC II Ictus 2cm lat MCL ICS V Sinistra Chest xray : cardiomegaly, conus pulmonalis prominent, calcification of the aorta Male/59yo Leucocyte 14000 Leucocyturia 3+ 20-25/hpf Male/59yo Albumin 2.75 Proteinuria 2+ 5. Urinary tract Infection
6. Hypoalbumine mia
albumi n
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