66 y/o malay Male

CC: dizziness and fatigue for few days, black stool for 3 days and 1st episode of vomiting of blood prior
admission to hsnz

Patient is well until 1w ago, alleged fall from his motorcycle while he is trying to ride on it. He injuried his
left wrist and he was given painkiller from private clinic. He was unsure of name of the medication but
he described it as dark red color, round pill. He took the medication before meals, 2 pills for 3x per day.
Few days later ,he started to feel dizziness, fatigue especially after work, and his wife realized he looked
pale. He had normal appetite but reduced oral intake as he feel like vomiting when eating, thus loss of
weight. Otherwise, he denied of fever, difficulty in swallowing, nausea, abdomen pain, yellow eyes,
bloatedness, easy fullness and burning sensation. No history of liver disease such as hepatitis and high
risk behavior such as multiple sexual partner and IVDA. 3 days prior admission, patient passed black
colour stool which is painless, no mucous discharge seen and he claimed to have difficulty passing stool
recent 1 month. Prior admission, he went to clinic besut for his black stool and after taking blood he
suddenly vomit blood, large in amount of blood is seen on his shirt, vomitus is red mix with black colour,
no food content and non-biliary. He fainted in the clinic and blood transfusion was given. Patient was
transferred to HSNZ emergency for further management.

Past illness: Previous hx of gastritis

Hx of sys ds: HTN for 6yrs (not well-controlled)

X surgery done bfr.

Diet: regular,malay food and dnt skip meal

Drug: Taking htn medication, denied of traditional medication and antacid and NKDA

Personal hx: Ex smoker (stop 10yrs ago), x alcohol, x drug absue

Social: Staying with wife and children in rumah teres with adequate electric and h20 supply

X recent hx of travelling to other countries

Systemic Review

Cardiovascular system There were no chest pain, orthopnea and paroxysmal nocturnal
dyspnea
Respiratory system No cough and hemoptysis
Central nervous system No symptoms of dizziness, headache, seizure, altered body
movement, tremors and focal neurological deficit.
 Gastro intestinal system No change in bowel habit and abdominal pain
Genitourinary system Normal urine color and frequency with no symptoms of
nocturia, dysuria, hesitance and incontinence.
Musculoskeletal system No joint, bone and muscle pain with full range of body
movement.

General examination:
Patient is alert, conscious and well cooperative, well orientation to time, space and person.
There is no anemic and jaundice on both eyes. Oral hygiene fair, tongue is moist, coated
no ulceration and no dental caries. There is no neck swelling, scar and engorged
veins,spider nivae. Upper limb examination, fine tremor or flapping tremor , both palms
are warm and moist, regular pulse and rhythm , good volume and normal character,
capillary refill time less than 2 seconds, no finger clubbing, cyanosis and koilonychias.
Lower limb examination no pitting edema and varicose vein.

100bpm

16bpm

1. Urinalysis

2. Full blood count

3. Blood urea, serum electrolytes and creatinine

4. Serum lipid profile

5. Fasting blood glucose level

6. Blood coagulation profile

7. Blood group cross matching (GXM)

8. Liver function test liver hepatitis and cirrhosis

9. Electrocardiogram (ECG)