1 Mirus/M/71 years old/IP 21
Chief Complaint:
• Black stool since 4 days ago
Present Illness History
• Black stool since 4 days ago. Stool with solid consistency. Frequency about twice per day.
• The Patient had trouble for sleeping since 1 month ago
• Bloody vomits 4 days ago, volume was about half of medium glass with frequency 1x. There
is no bloody vomits after that.
• Fatigue and Weakness since 4 days ago
• Look Pale since 4 days ago
• There is no Fever
• There is no cough
• There is history of black vomit and black stool last year
• Micturition in normal limits.
• The patient has known as liver cirrhosis since 2022. Esofagoduodenoscopy has been done
2023 with result Varices Esofagus grade I with gastritis erosive.
Past illness history
• History of DM (-)
• History of HT (-)
• History of Liver disease (+)
Family illness history
• There is no family member suffered from
the same disease
Physical Examination
VII
• General Appearance : Moderate
• Consciousness level: Composmentis
• BP : 139/70 mmHg
• HR : 90 x/minute
• RR : 18 x/minute
• T : 37,1º C
• SaO2 : 97%
• Skin VII
• Warm
• Eye
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH2o
– Spider Navy (+)
• Lung: VII
– Inspection: statically & dynamically symmetric both of lung
– Palpation: fremitus equal both of lung
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor:
– Inspection: ictus is not seen
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-), caput medusae (-), collateral vein (-)
– Palpation: Soepel, hepar and lien not palpable
– Percussion: Tymphani
– Auscultation: bowel sound (+) N
– CVA : flank pain (-/-)
• Extremities:
– Oedema pretibia -/-
– Palmar Erythema (+/+)
– Patologic reflex -/-
– Phyisiologic reflex +/+
Laboratory
Items Value
VII
Hb 6.3
Ht 19
WBC 5.580
Platelet 220.000
RBG 105
Ur/Cr 83/2.1
Na/K/Cl: 133/4.1/103
Chest X-Ray VII
ECG VII
Working Diagnosis
- Melena Variceal Bleeding cb Esophageal Varices Rupture
- Liver Chirrosis PNSD CTP B with Hepatic Encephalopathy Grade I
- Gastritis Erosiva
- Moderate Anemia Nomocytic Normochromic cb Acute bleeding
- Hepatorenal Syndrome
- Osteoarthritis Genue Bilateral
Therapy
Rest/Liquid Meal Liver Diet II
IVFD Comafusin ; Triofusin ; Nacl 0.9% / 8 Hours per kolf
Bolus Sandostatin 2 Amp continued with Drip Sandostatin 2,08cc/hours
Inj,Vitamin K 3x10mg
Inj.Transamin 3x500mg
Inj.Omeprazole 2x40mg
Sucralfat syr 3x10cc
Lactulac Syr 3x30cc
Spironolakton 1x100mg
Madopar 3x1 tab
Transfusion PRC 2 unit
Paracetamol 3x750mg
Plan
Check complete blood count
Urinalysis
Rontgen Genue AP/Lateral
EGD
