Morning Report Case: Desember 15 TH 2016

MORNING REPORT CASE
Desember 15 th 2016
PATIENT’S IDENTITY
Name : GF
Gender : Male
Age : 19 y.o
Address : Jl Pasanggaran, gg Pancusari no 1,
Sesetan
Ethnicity : Manggarai/Indonesian
Religion : Catholic
Job : Porter in Airport
Married Status : Unmarried
TC : 16.35 wita
ANAMNESIS
• Chief complain : Vomit

• Present History :
• Patient came to the hospital with chief complaint of vomitting and
nausea since morning BATH. The vomitting was said to be ± 7
times since morning. He said there was blood in his vomit and he
said sometimes the vomitn was blackish red in colour. The total
volume of vomit was about ± 600 cc. The nausea and vomitting did
not become better with eating. Even after eating, he said he vomitted
all the food that he has been eaten. The patient also complained of
having heartburn. The heartburn was felt since morning too.
• History of fever was denied. Defecation and micturation were said to

be normal.
Past medical history :
3 months ago patient was admitted to the hospital for ± 1 week because of
the same complaint. After being discharged patient never come back for
control. He was planned to do esophagogastroduodenoscopy but he never
come for the appointment. Patient has been having the the same
complaints of heartburn, nausea and vomitting since 9 years old and was
treated in hospital in Manggarai.
History of food and drugs’ allergy were denied.
History of other systemic diseases such as heart ds, kidney ds, liver ds,
diabetes mellitus, hypertension was denied.
• Medication history : Patient said he had consumed antacid and
sucralfat to relieve the heartburn and nausea since 3 months ago.
Patient also bought medication from pharmacy to relieve the
symptoms but forgot the name of the drugs.
• Family history : Patients denied if there is family feel the same
complaint as patients at this time. A history of systemic diseases
such as heart disease, kidney, liver, diabetes mellitus, hypertension in
the family was denied.
• Social history : Patient work as porter at the airport and often
come home from work until late at night. Patient also has the habit
of drinking alcoholic drinks.
PHYSICAL EXAMINATION
General appearance : Moderately ill

Level of consciousness : E4V5M6
Vital Sign:
• BP : 120/80 mmHg
• PR : 100 x/min
• RR : 20 x/min
• tax : 37,3°C
Weight : 60 kg
Height : 165 cm
BMI : 22,05 kg/m2
STATUS GENERAL
Eyes : anemis -/- icteric -/- RP +/+ isocoric

ENT : tonsil T1/T1 , pharing hyperemis -/-
Neck : JVP ± 0 cm H2O, lymph node enlargement (-)
Chest examination
 Cor : inspection : ictus cordis unseen
palpation : ictus cordis unpalpable
percussion : UB (ICS II PSL D et S), RB (ICS IV
PSL D), LB (ICS V MCL S)
auscultation : S1S2 single, regular, murmur (-)
 Pulmo : inspection : symetric (static and dynamic)
palpation : vocal fremitus N/N
percussion : sonor / sonor
ausculation : vesikuler(+/+), rhonki(-/-), wheezing (-/-),
ABDOMEN
•I : distensi (-)
• Aus : BS (+) ↑
• Pa : tenderness (-), Hepar and lien unpalpable,
quick return of turgor (< 2`)
• Pe : Tympanic (+)
EXTREMITIES
• Warm (+) of 4-extremities, oedema (-)
LABORATORY EXAMINATION (15
DESEMBER 2016)
Parameter Result Unit Remarks Reference range
WBC 9,47 103/μL 4,10 – 10,90
-Ne 83,4% % H 37,00 – 72,00
-Ly 10,97% % L 13,0 – 40,0
-Mo 4,51% % 0,00 – 14,00
-Eo 0,33% % 0,00 – 6,00
-Ba 0,79% % 0,0 0 – 1,00
RBC 6,24 % H 4,40 – 5,90
HGB 16,20 g/dL 12,0 – 16,0
HCT 51,67 % 36,0 – 46,0
MCV 82,77 fL 80,0 – 100,0
MCH 25,95 Pg L 26,0 – 34,0
MCHC 31,35 g/dL 31 – 36
RDW 11,78 % 11,6 – 14,8
PLT 307,30 103/μL 140,0 – 440,0
Parameter Result Unit Remarks Reference
range
SGOT 18,2 U/L 11,00-27,00
SGPT 16,2 U/L 11,00-34,00
Albumin 4,5 g/dL 3,40-4,80
BUN 9,0 mg/dL 8,00-23,00
Creatinine 0,71 mg/dL 0,50-0,90
Na serum 144 mmol/L L 136-145
K serum 3,5 mmol/L 3,50-5,10

ANTI H.PYLORI (26 SEPTEMBER
2016)
Parameter Hasil Nilai Rujukan
Anti H. Pylori IgG Positif :1.03 Non Reaktif <0.75
Equivocal 0.75-1.00 Reaktif
>=1.00
WORKING DIAGNOSIS
Observation Hematemesis et cause suspect gastritis

erosion dd peptic ulcer
PLANNING
• Hospitalized
• IVFD RL ~ 20 dpm
• Pantoprazole bolus 80 mg iv continue with drip 8mg/hour
• Amoxicilin 1000 mg @12 hours PO
• Claritromycin 500 mg @12 hoursPO
• Antasida 15 mg @ 8 hours PO
• Sucralfat 15mg @ 8 hours PO
• Fasting
• NGT – Gastric lavage according to protocol
• @ 2 hours when there is fresh blood
• @ 4 hours when there is stocell
• @ 6 jam when clear fluid is obtained
Planning Diagnostic :
• Esophagogastroduodenoscopy (when stable)
Monitoring :
• Complaints and vital sign
• Fluid balance
THANK YOU

Morning Report Case: Desember 15 TH 2016

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MORNING REPORT CASE

• Chief complain : Vomit

• History of fever was denied. Defecation and micturation were said to

History of food and drugs’ allergy were denied.

General appearance : Moderately ill

Eyes : anemis -/- icteric -/- RP +/+ isocoric

SGPT 16,2 U/L 11,00-34,00

Albumin 4,5 g/dL 3,40-4,80

BUN 9,0 mg/dL 8,00-23,00

Creatinine 0,71 mg/dL 0,50-0,90

Na serum 144 mmol/L L 136-145

K serum 3,5 mmol/L 3,50-5,10

Observation Hematemesis et cause suspect gastritis

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