dr.
Dheni
MORNING REPORT
Date : Thursday, January 28th 2021
Physician in charge
I : dr. Vidi, dr. Rama, dr. Jonny
II Consultation : dr. Dimas
II HCU : dr. Dheni
II UGD : dr. Ferdi, dr. Pandu, dr. Dita
Chief on duty : dr. Dipto
Consultant on duty : dr. Siti Fatma, SpPD
Facilitator : dr. Siti Fatma, SpPD
Summary of Database
Mrs. A/ 38 yo/ Ward 26
Autoanamnesis
Chief Complaint: black tarry stool
History of Present Illness:
Patient referred from previous hospital with chief complaint about black tarry stool during
defecation for the last 3 day before her admission, the frequency was > 5 times each day and the
amount was about half a glass (300-350 cc) and consistency was mushy, slime (-). When she
hospitalized in previous hospital, she got 2 times transfusion of red blood, 1 pack each day, but the
black tarry stool didn’t relieve yet.
Patient also complained epigastric pain since 3 months ago, the pain was relieving when he ate
and became aggravated when she late ate meal. The patient has been easily became fatigue ever
since. She didn’t complaint about chest pain. She also complained about nausea and decrease her
appetite since 1 week ago. She didn’t complained about vomit.
History of drugs consumption and “Jamu” was denied. Hystory of DM and hypertension was
denied. Hystory of Jaundice and liver disease was also denied.
Summary of Database
Past Medical History:
History of hospitalized since 2 days before she referred from private hospital with black tarry
stool and got transfusion of PRC medication. Before her last hospitalized, she didn’t has
remarkable medical history
Family History:
It was unknown to her whether or not any family members had similar complaints.
Social History:
She was married and lived with her husband. She worked as a grocery trader. She didn’t
consumed alcohol. She also didn’t had smoke habit before.
Review of System:
Patient was capable of communicating properly. The black tarry stool defecation still occur
during her stay in the ER, the patient can urinate normally by herself.
Physical Examination
General appearance looked moderately ill Saturation of O2 99% on RA
GCS 456, Compos Mentis
BP 132/56 mmHg PR 119 bpm irregular RR 20 tpm Tax 36,8oC
Head Anemic conjunctiva (+), NGT production was clear
Neck Within normal limit
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular -
|- -|-
Sonor | Sonor Vesicular | Vesicular -
|- - |-
Cardio Ictus invisible, palpable at ICS V MCL (S)
S1 S2 single, regular, murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm
Lien/ Traube space tympany, Epigastric pain (+), VAS 3/10 with provocation
Extremities Edema (-), pale (+), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-)
RT Melena (+), mass (-), TSA (+)
Laboratory Findings (27/1/2021)
LAB VALUE NORMAL LAB VALUE NORMAL
Haemoglobin 3,4 11,4 – 15,1 g/dL PPT 10,90” 10,3”
Leucocyte 25.210 4.700 – 11.300 /µL APTT 18,5“ 25,1”
HCT 10,20% 38 - 42% Ureum 29,3 16,6 - 48,5 mg/dL
Thrombocyte 185.000 142.000 – 424.000 /µL Creatinin 0,63 < 1,2 mg/dL
MCV 75 80-93 fl eGFR 101,63
MCH 25 27-31 pg Natrium 132 136 – 145
Eo/Bas/Neu/ 0,1/0,5/57,4/27 0-4/0-1/51-67/25-33/2- Kalium 3,58 3,5 – 5,0 mg/dL
Limf/Mon ,3/8,7 5
RBG 112 < 200 mg/dL Chloride 110 107 mg/dL
ECLIA Non Reactive Non Reactive SGOT 24 0-32 mg/dL
HbSAg Non Reactive Non Reactive SGPT 13 0-35 mg/dL
Anti HCV Non Reactive Non Reactive Albumin 2,10 3,5 – 5,5 g/dL
Chest X-Ray (27/1/2021)
Chest X-Ray (27/1/2021)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S were dome-shaped
• Phrenicocostalis angle D and S were sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 55%, shape N, elongation aorta (-), cardiac
waist (+)
Conclusion: Cor and Pulmo was normal
Electrocardiography 27/1/2021
Electrocardiography (27/1/2021)
• Sinus tachycardia, HR 126 bpm regular
• Frontal Axis : Normal
• Horizontal Axis : Normal Rotation
• P wave : 0,08 s
• PR interval : 0,16 s
• QRS complex : 0,08 s
• Q wave : Normal
• QT interval : 0,36 s
• ST segment : J point Isoelectric
• Others : T inverted lead II,III,aVF, V1-V6
Conclusion : Sinus tachycardia with HR 126 bpm
Rockall Scoring
Rockall Score (Pre-Endoscopy): 4
Blatchford Scoring
Blatchford Score : 7
(Required Intervention)
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL Idx PDx PTx PMo&Ed
1. Melena + 1.1 Non Variceal Endoscopy Non pharmacology S, VS, VAS
Mrs. AW/ 38 yo/ Ward 26
Epigastric Bleeding - Bed rest score, signs
Subjective tenderness - Fasting, waiting result of bleeding,
- Black tarry stool during 1.1.1 PUB Gastric lavage until clear oxygen
hunger
defecation
- Epigastric pain recurrence since 1.1.2 Gastritis Pharmacology
Erosiva - NGT insertion, Gastric PEdu :
3 month ago
- Nausea and decrease appetite lavage/8 hours, start fluid Educate the
1.1.3 Mallory diet 6x200cc/24 hours if patient about
since 1 week ago Weiss tear Gastric lavage was clear the diagnostic
- IVFD NS 0,9% process
Objective
1500cc/24hours which was
‐ Anemic conjunctiva (+) - IV Lansoprazole 60 mg planned to
‐ Epigastric tenderness (+), with VAS 3/10
continued with drip evaluate the
on provocation
‐ Extremity: Pale (+) 6mg/hours patient’s
main
problem.
Lab 27/1/2021
DL :3,4/25.210/185.000/ 10,20% The result
may decide
MCV/MCH : 75/25
PTT: 10.9 (10,3) the best
course of
APTT: 18,5 (25,1) treatment for
INR: 0,99
the patient.
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Anemia 2.1 Acute Blood SI, TIBC, Non pharmacology S, VS, Oxygen
Mrs. AW/ 38 yo/ Ward 26
Gravis Loss Feritin - Bed rest hunger,
Subjective Reaction of
- Black tarry stool during 2.2 Fe Pharmacology Tranfusion
Deficiency - Transfusion of PRC 2
defecation since 3 days ago
- Epigastric pain pack/day until Hb >8g/dl PEdu :
- She felt easily became fatigue Caused of the
anemia
Objective
Anemic conjunctiva (+)
Epigastric pain (+) VAS 3/10 with provocation
Laboratory (27/1/2021)
DL : 3,4/25.210/185.000/ 10,20%
MCV/MCH : 75/25
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Leukocytosis (-) (-) Non pharmacology S, VS, Signs of
Mrs. AW/ 38 yo/ Ward 26 dt reactive (-) bleeding
Subjective
- Black tarry stool during defecation Pharmacology PEdu:
- Epigastric pain (-) Leucocytosis
itself can
reflect the
Objective
BP 101/48 (ER) -> 132/56 (Ward) severity of
the bleeding
HR 124 bpm (ER) -> 119 bpm (Ward) episode, and
RR 20 tpm is associated
Leucocyte : 25.210 /uL
with a more
complicated
course
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. AW/ 38 yo/ Ward 26 4. Severe 3.1 Low Intake Non pharmacology S, VS, Signs of
Hypoalbuminem When patient got start fluid bleeding
ia 3.2 Hypercatabolic diet, give fluid diet 6x200 cc,
Subjective state with extra protein PEdu:
- She felt nausea without vomit and
decrease of her appetite Leucocytosis
- Epigastric pain Pharmacology itself can
(-) reflect the
severity of
Objective the bleeding
BP 139/56 mmHg
HR 119 bpm episode, and
is associated
RR: 20 tpm with a more
SpO2: 98% on Nasal Canule 4 lpm complicated
Abdomen: ascites (-)
Extremity: Edema -/- course
Problem Analysis
Anemia Gravis Easily felt fatigue/weak
Hypoalbuminemia
Melena
Low Intake
Epigastric pain
Non variceal bleeding recurrence
since 3 months
Problem Analysis
Problem Theory
Melena dt
Upper GI
Bleeding
Problem Analysis
Problem Theory
Melena dt
Upper GI
Bleeding
Problem Analysis
Problem Theory
Melena dt
PUD
Management Analysis
Key Message Pathophysiology
Key Message Management
‐ We planned to perform a diagnostic process which
involves endoscopy examination based on patient’s
main problem which is melena in order to decide the
best course of management based on the result of the
endoscopy.
‐ Other management include symptomatic reliefs and
non – pharmacologic treatment.
Key Message Social
‐ Educate the patient and his family regarding his
complaints, especially the black tarry stool, whereas
the cause of the complaint may vary and definitive
diagnostic process is needed.
‐ The understanding of the patient may affect the
compliance toward the examination and may very well
contribute to the success of the diagnosis.
Condition This Morning
GCS : 456
BP : 130/62 mmHg
HR : 92 bpm
RR : 20 tpm
Tax : 36,6o C
SaO2 : 99% on nasal canule 4 lpm
Prognosis
• Ad vitam : dubia
• Ad functionam : dubia
• Ad sanationam : dubia
