Patient Identity

Sex : Male
Name : Mrs. E
Age : 58 y.o
Occupation : Wiraswasta
Hospitalized since : July , 26 th 2017
 Chief Complaint : Vomiting blood
Vomiting blood since 2 days ago
Muntahnya bewarna coklat, encer, dan berbau
amis
Patient also complained about no cough
But patient frist cough mouth ago
Patient said he felt pain on epigastric regio
 Loss appetite
Patient said the entry body
History of traveled across city not found (-)
 Physical Examination

BP= 170/90 mmHg HR: 73 x/minute RR = 22 x/minute T : 37,6 C

General Condition : moderately ill GCS E4V5M6

Head and Skin Anemis conjungtiva Rash (-), petekie (-)
(-)
Icteric sclera (-)

Neck JVP= R + 2 cmH2O

Thorax: Cor: Ictus cordis unseen, palpapble on ICS V Midclavicula line sinistra.
Cardiomegaly (-)
LHM ICS V midclavicula line sinistra
RHM Linea parasternal dextra ICS IV
S1,S2 single, Murmur (-), extra sound (-)

Lung: Fremitus fokal simetric

Simetric S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
 Physical Examination

Abdomen Bowel sound 10x/menit

Tenderness
- - -
- - -
- - -
Organomegali not found(-)
Shifting dullnes(-)

Ekstremitas Edem (-), deformity (-)

Laboratory Findings
Component Value Normal Range

Hb 14,0 13,0-17,5g/dl

Leukocyte 12,4 4,0-10,5 ribu/ul

Erythrocyte 5,29 4.5-6.00 juta/ul

Hematocrite 39,9 40.00-52000

vol%
Thrombocyte 236 150-350 ribu/ul

RDW-CV 13,7 12,1-14 %

MCV 75,4 80,0-97,0 f

MCH 26,5 27-32 pg

MCHC 35,1 33-37%

Component Value Normal range

Ureum 10,0-50,0
mg/dl

Creatinine 1,5 0,6-1,0 mg/dl

SGOT 864 4,0-11,0 U/l

SGPT 390 2,5-7,0 u/l

 A : Susp.Hematomesis Sup gastritis
Susp.Hepatitis

P: IUFD RL 20 tpm
SNMC 20 tpm
Inj.ketorolac iv
Inj ranitidin
Inj Omz 1x1
Inj, metoclopramide /8jam 3x1
Cek Usg abdomen
Cek protein total, albumin, HBSAG