MR Hematemesis-Ulkus Peptikum

7/25/2019 MR Hematemesis-Ulkus Peptikum

1/19

MORNING CASE REPORT

12THJUNE 2011


2/19

IDENTITY

Name : SH

Age : 55 y.o

Gender : ema!e

E"#n$%$"y : Ja&ane'e

Re!$g$on : M('!$m

Addre'' : )r. T$ngga! Sar$ Ta*anan.

MR No. : 01.+,.-+.2

T$me o adm$''$on : 12 J(ne 2011/ 1.15 PM


3/19

ANAMNESIS

CC: bloody vomiting

Present history:

T#e a"$en" %om!a$ned o &om$"$ng + day' )ATH and *!oody&om$"$ng '$n%e day' )ATH. T#e *!oody &om$"$ng $' 'a$d "o *e*!a% $n %o!or/ m$3ed 4$"# ood "#a" ea"en/ re(en%y 2 "$me'/

&o!(me 6 1 g!a'' o a(a. T#e a"$en" a!'o %om!a$n" gna4$ng a$n on (er a*domen '$n%e

2 4ee' ago. Pa$n o%%(r' '#or"!y a"er ea"$ng and er'$'" e&en '#e&om$"$ng. T#e a$n rad$a"ed o'"er$or!y or 'read "o a!! reg$on o'"oma%#. Pa"$en" 'ome"$me' ee! d$'%omor" on #er '"oma%#.

Co(g# 789/ '#or"ne'' o *rea"# 789 e%rea'e o ae"$"e or "#e a'" 2 mon"#'/ a" "#a" "$me '#e o"en

ee!' a$n on #er '"oma%# #o4e&er $" d$dn;" o!!o4 *y &om$""$ngye".


4/19

)!a% and #ard '"oo! 7


5/19

Past History:

Pa"$en" a!'o %om!a$n$ng &om$"$ng '$n%e ,year' ago/ &o!(me6 100 %%.

- "$me' "rea"ed $n #o'$"a! *e%a('e o&om$"$ng.

Ha&e med$%a"$on d$agno'e 4$"# Ga'"r$"$'.


6/19

Family History: Her mo"#er #a' 'ame %om!a$n 7*!oody

&om$"$ng9

Social and Daily habits: Ea" $rreg(!ar!y 7


7/19

Physical Examination

General appearance : moderate

Level of consciousness/GCS : C:!"#$%

#ital Sign:

&P: '((/ %( mmHg

)): *% +/min

P): '(( +/min

ta+ : ,%-.C


8/19

!yes : Anem$' 7


9/19

A*domen : In' : d$'"en"$on 789/ %o!a"era!789/ %a(" med('ae 789

A('% : *o4e! 'o(nd' 7


10/19

a*ora"ory E3am$na"$on'

F3LL &L44D C4301

Parameter Result Unit Remark Reference range

WBC 8,5 103/L H 4,1 10,9

-Ne 14,2 (82,1%) 103/L H 2,5 7,5

-Ly 1,7 (9,9%) 103/L 1,0 4,0

-Mo 1,2 (7,0%) 103/L 0,1 1,2

-Eo 0,1 (0,7%) 103/L 0,0 0,5

-Ba 0,1 (0,3%) 103/L 0,0 0,1

RBC 2,7 106/L L 4,00 5,20

HB 8,4 !/"L L 12,00 16,00

HC# 24,4 % L 36,0 46,0

MC$ 90,4 L 80,0 100,0

MCH 31 &! 26,0 34,0

MCHC 34,3 !/"L 31,0 36,0


11/19

PARAMETER RESUT

PT 12 Norma!.er*edaan on"ro!

2 de"$

INR 1/1 0/D > 1/1

ONTRO PT 12/+ 8

APTT /0 Norma!.

Per*edaan on"ro! - de"$

ONTRO APTT +/

P5)5!1!) H5S6L S51350 )373850

)!ood$ng T$me 1;00 Men$" 1/008/00

C!o"$ng "$me -;0 men$" 5/00815/00


12/19

%!$n$%a! %#em$'"ry

Parame"er Re'(!" Un$" Remar' Norma! Range

SGOT 12,3 IU= 11/008/00

SGPT 7,9 IU= 11/00850/00

)UN 35,480 Mg=d! H ,/0082/00

Crea"$n$n 0,6 Mg=d! H 0/-081/20

Random )!ood G!(%o'e 10, Mg=d! -0/0081+0/00

)$!$r(*$n "o"a! 0,33 Mg=d! 0/0081/0

)$!$r(*$n Ind$re%" 0/2+ Mg=d! 88888

)$!$r(*$n d$re%" 0/0D Mg=d! 0/00 80/0

A!a!$ #o'a"a'e 53,97 Mg=d! 5/00 > 12,/00

To"a! Pro"e$n 5,92 Mg=d! L /+0 > ,/0

A!*(m$n /0D Mg=d! L /+0 8+/,0

G!o*(!$n 2/15 Mg=d! 8888


13/19

)!ood ga' ana!y'$'

Parameter )esult 3nit )emar2s )eferencerange

pH .9$( ; 1inggi .-,$ < .-"$

pC4* ,.- mmHg )endah ,$-(( < "$-((

p4* ',( mmHg )endah (-(( < '((-((

Hct *% = )endah ,.-(( < "-((HC4,; ,"-. mmol/L **-(( < *%-((

1C4* ,$- mmol/L *"-(( < ,(-((

&!>&? ''-@ mmol/L ;* < *

S4*c @$-* = ;;

1Hbc -'( g/dL )endah ',-(( < '-((

0a ',$ mmol/L ',$-((

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MR Hematemesis-Ulkus Peptikum