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Patients Identity
Name
:
Sex
:
Age
:
Weight
:
Occupation
:
Hospitalised since
Mr. A
Male
52 yo
70 kg
employee
: December 1 th, 2015
Physical Examination
General appearance
Blood Pressure
100/80 mmHg
Pulse Rate
Respiration rate
T ax
Head
Neck
JVP R + 4 cmH2O at 30
Chest Heart
Lung
position
Rh - -
Wh - -
Abdomen
Extremities
S/S
Laboratory Result
Items
Result
Normal Value
Unit
Hemoglobine
5.9
14.00 - 18.00
g/dl
Leukocyte
13.1
4.0 10.5
thousand/ul
Eritrocyte
2.14
4.50 6.00
million/ul
Hematocrit
19.2
42.00 52.00
Vol%
Trombocyte
173
150 450
Ribu/ul
RDW-CV
17.9
11.5 14.7
MCV
74.1
75.0 96.0
Fl
MCH
27.5
28.0 32.0
Pg
MCHC
30.1
32.0 38.0
Hematology (30-11-2015)
Items
Result
Normal Value
Unit
151
<200
mg/dl
SGOT
130
0 - 46
U/l
SGPT
71
0 - 46
U/l
Ureum
226
10,0 50,0
mg/dL
Creatinine
2.1
0,7 1,4
mg/dL
Result
Normal Value
Unit
Natrium
136
135-146
mmol/l
Kalium
2.8
3.4 5.4
mmol/l
122.2
95-100
mmol/l
Items
Chlorida
PL
IDx
Male/57 yo
1.
Hematem
esis
Melena
1.1 Varices
Esophagus
1.2 Peptic ulcer
1.3 Gastritis
erosif
2.
Anemia
HN
Anamnesis
-bloody vomit
-melena
-Pain in the upper right
stomach
Physical Examination
Blood preasure :
100/80
Abdomen:
hepatomegaly (+)
Pain (+) right
hipocondriaca
Ekstremitas inferior:
Edema (+/+), pitting
edema (+/+)
Laboratory:
Hb: 5.9
Leukocyte: 13.9
Eritrocyte: 2.14
Hematocrite: 19.4
MCV: 74.1
MCH: 27,5
SGOT: 130
SGPT: 71
Ureum:226
Creatinine: 2.1
PDx
PTx
DLO
SGOTSGPT
Albumin
PT /APTT
Seromarker
hepatitis
USG
abdomen
OMD
IVFD NS 20tpm
Inj Omeprazole 2x1
Inj Asam Tranexamat 3x1
Inj Vit K 3x1
PO: Sucralfat 3xI C
DLO
PMo
VT
BR
Thank you