CASE REPORT

Mentor:
dr. Riki tenggara, Sp.PD

Presentants :
Kirana perwitasari 2014.061.
Herafani 2015.061.155
Najwa khairana 2015.061.156
Patient Identity
Name : Mrs. SY
Age : 62 years old
Address : Rawa Bebek
Religion : Moslem
Occupation : Housewife
Admission date : January 18th 2017
Examination date : January 19st 2017
History
Chief complaint:
General weakness for the past 6 hours
before admitted to the hospital.
Additional complaint:

Black coloured stool since 1 month before

admitted to the hospital.
History of Present illness
A 62-year-old female patient presented with general
weakness for the past 6 hours before admitted to
the hospital. She felt a sudden fatigue for the first
time in her life and never experienced it before.She
tired more easily than before.The tiredness felt was
gradually increasing as she done any activities until
she wasnt able to walk but will get better with
resting.
 The patient was then admitted to the
Puskesmas and discovered that her Hb
level was 5 g/ dL. Then, patient was sent
to Atma Jaya Hospital.
 The patient also complained about her
black coloured stool since 1 month before
she was admitted to the hospital, with
tender consistency. There was no fresh
blood nor mucus coming out with the stool.
Other complaints such as fever, abdominal
pain, nausea, and vomit was absent.
History of Past Illness
History of hypertension was absent.
History of diabetes mellitus was absent.
History of Habit
The patient has a habit of taking
traditional drinks (jamu) for the past 20
years. The patient also takes Neo-
Rheumacyl routinely every time she
feels low back pain, and this happens for
the past 3 months.
Family History of Disease
Theres no one in the family has a
history of the same complaints.
History of hypertension (-)
History of DM (-)
Physical Examination
General condition : moderate ill
Consciousness: conscious, GCS 15
Nutritional status :
Weight : 60 kg
Height : 150 cm
BMI : 26.6 kg/m2 overweight
Vital sign
Blood pressure : 160/80 mmHg
Heart rate : 80 x/minute, reguler, full pulse
Respiratory rate : 18 x/minute, thoracoabdominal type
Temperature : 36.8C
Physical Examination
Head : normocephaly, deformity (-)
Eyes : pallor conjunctiva +/+, icteric sclera -/-,
pupil isochor 3mm/3mm, light reflex +/+
Ears : cerumen -/-, secret -/-, meatus akustikus
eksternus +/+
Nose : the nasal septum bone located in the
middle, crepitation -, secret -/-
Mouth: oral mucosa and lips are moist, tonsil T1/T1
Physical Examination
Neck : JVP 5 + 2 cmH2O, no masses or lymphadenopathy
Chest
Lung:
I: symmetric chest expansion, no use of additional breathing
muscle
P: symmetric chest expansion, symmetric fremitus tactile on
both lung
P: resonant on both lung. Liver dullness on ICS V linea
midclavicularis sinistra
A: vesicular +/+, ronchi -/-, wheezing -/-
Physical Examination
Heart:
I : No cardiac impulse visible
P: No cardiac impulse felt
P: Upper border : ICS II linea parasternalis sinistra
Left border : linea axillaris anterior
Right border : linea parasternalis dextra
A: S1 & S2 regular, murmur -, gallop -
Abdomen:

I : flat, no scars
A : bowel sounds present + 6 x/min
P : timpanic, shifting dullness
P : no tenderness or guarding, no enlargement of hepar/spleen
Physical Examination
Extremities : warm extremities, CRT <2, edema
(-)
Back:
I: normal vertebra alignment, symmetric movement
(static and dynamic)
P: symmetric, tactile fremitus +/+ (symmetric)
P: resonant +/+
A: vocal fremitus +/+, vesicular +/+, ronchi -/-,
wheezing -/-
Laboratory Test
CBC(January 18th 2016) Result Normal Range
Hemoglobin 5.1 g/dL 12 15.8 g/dL
Hematocrit 19% 36 - 48%
Thrombocyte 332.000/uL 165.000-415.000/uL
Leucocyte 6.800 3540-9060 /uL
Erythrocyte 3.320.000/uL 4.000.000 5.200.000/uL
MCV 58.1 fL 84 96 fL
MCH 15.4 pg 26.7 31.9 pg
MCHC 26.4 g/dL 32.3 35.9 g/dL
Basophile 0 02
Eosinophil 1 06
Bands 7 05
Segment 60 40 70
Lymphocytes 25 20 50
Monocytes 7 48
Laboratory test

Test (January, 18th 2016) Result Normal Range

Random Blood Sugar 106 60 140
Ureum 22 17.1 49.2
Creatinin 0.8 0.5 0.9

Ferritin < 10.00 35 350

SI 40 41 141
TIBC 286
Electrocardiogram
 RESUME
Woman, years old, came to emergency department
with general weakness since 6 hours prior to
admission as a chief complaint. The complaint was
felt when she wasnt doing any significant or hard
activity and got better at rest. She went to a primary
healthcare facility and found out her Hb : 5 mg/dL.

She also complaint of having black-coloured stool

since 1 month prior to admission. The consistency of
the stool was soft, no fresh blood and mucus seen,
ASSESSMENT
Mrs. SY, 62 years old with
Anemia gravis ec melena ec susp. Gastric
ulcer
Hypertension stage II
Treatment
Hospitalized and atmitted to the war
IVF Asering 5 1500 cc/24 hours
Pantoprazole drip 8 mg/hour
Inpepsa 4 x 15 cc
Tranexamic acid 3 x 500 mg
Vitamin K 3 x 1 amp
PRC transfusion
Furosemide 20 mg IV after transfusion
FOLLOW-UP EXAMINATION
Laboratory tests :
Complete blood count
Endoscopy
 Prognosis ad vitam : ad bonam
Prognosis ad functionam : dubia
Prognosis ad sanationam : dubia ad
malam