Melena et Causa Gastritis Erosiva and Hypertension
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Transcript of Melena et Causa Gastritis Erosiva and Hypertension
DUTY REPORTMelena et causa Gastritis Erossiva
Hypertension
Supervisor : Dr. dr. Soroy Lardo, SpPD FINASIMJohanes Hansen
Yuwen Fondly HulkyawarDivision of Infectious and Tropical Diseases
Indonesia Army Central Hospital Gatot SoebrotoFaculty of Medicine UKRIDA
Name : Mr. AdjisAge : 80 y.oDate of Birth : 5 May 1936Adress : PenjaringanReligion : MoeslemJob : EmployeeEducation : Junior High SchoolMarried
Anamnesis
Chief Complain:• Black stool for a day
Anamnesis
History of Present Illness:• Patients was having black tarry stool since a day ago with
a liquid consistency since 2 days ago for about 100 cc every bowel elimination. Patients Bowel elimination was about three times a day. The patients also having chronic abdominal pain for 20 years at the upper abdomen, Patients vomit once a day without blood. Patients had reduced appetite since 2 days ago. No History of having long term use of NSAID and steroid. The patient used to have antacid to reduce the abdominal pain
AnamnesisPast History• Hypertension(+) since 1986 • Chronic Gastritis since 1996• Hepatitis (-)
Family HistoryHypertention (+)DM (-)
Anamnesis
Drug History• Amlodipin • Unknown other heart drugs.
Social History• Smoking (+) since in junior high school. 1-2
pack a day• Alcohol (-)
Physical Examination
Consiousness : Compos mentisVital Sign
BP : 140/60 mmHgHR : 70 x / minute, regularT : 36.5 0CRR : 19x / minute
Physical ExaminationHead : NormocephalHair : No LessionEye : Pupils round and symmetric, reactive to light, conjunctival pallor -/-, jaundice -/-, nystagmus -/- strabismus -/-Nose : Smell Intake, Turbinate pink, no dischargeEars : Symmetric. Tragus, anti-tragus, and pinna free of abnormalities, canal patent drums intactThroat : No Exudates, no erythema, no swelling.Mouth : No sores or ulcers, teeth (-)Neck : No Palpable lymph nodes
Physical Examination
Thorax (Lungs)Inspection: Symmetric while breathingPalpation : Vocal fremitus right = leftPercussion: resonant sound bilaterallyAuscultation: Vesicular bilaterally(+), Rhonki (-),
wheezing (-)
Physical Examination
Thorax (Heart)Inspection : No Visible Ictus cordisPalpation : Ictus cordis at ICS 5 linea midclavicula sinistraPercussion : NormalAuscultation: Normal S1-S2 are heard, murmur (-), gallop (-)
AbdomenInspection : Normal CountourAuscultation: increasing bowel movementPalpation : No palpable masses, pain when palpating epigastrium regionPercussion : Shifting dullness (-)
• Rectal Touche– Sfingter Ani <<– Ampula not collapsed– no masses at palpation– No pain at palpation– Prostate getting hypertrophy approximately 5 cm– No blood after doing rectal touche
LabsExamination Result
Hb 12,2* 13 – 18 g/dL
Ht 36* 40 – 52 %
Eritrosit 4.1 4,3 – 6,0 juta/uL
Leukosit 4030 4800 – 10800 / uL
Trombosit 246.000 150000 – 400000 / uL
LabsExamination Result
MCV 89 80 – 96 fL
MCH 29 27 – 32 pg
MCHC 32 32 – 36 g/dL
• Ureum 21 20-50 mg/dl
• Creatinine 0.8 0,5-1,5 mg/dl
• Blood Glucose 92 <140 mg/dl
LabsExamination Result
Natrium 143 135 – 147 mmol/L
Kalium 4.0 3.5 – 5.0 mmol/L
Cl 109* 95 – 105 mmol/L
Problem List
1. Melena et causa Gastritis Erossiva2. Hypertension
Black Tarry Stool
Anamnesis Physical Examination
Laboratory Result
Labs shows minimally
increase of Cl, minimally
decrease of HB, decrease
of HT
Clinical manifestation(acute clinical):1. Epigastric pain (+)2.Conjungtival pain (-)3. Weakness (-)4. Anorexia (-)5. Tacicardy (-)Chronic clinical:1. Weight loss (-)Drug history:1. NSAID (-)2. aspirin (-)3. Antiplatelet (-)4. Bismuth & iron (-)5. Anticoagulant (-)Past history:Chronic Drug Gastritis (+)Hepatitis (-)Smoking (+)Alcohol abuse (-) Barthel Index (Indeopendent)
Vital sign:- BP: 140/60 mmHG- HR: 70 x/mins- RR: 19x/mins- T: 36,5
Abdomen:- Epigastric pain
RT:- Sfinter ani <<- No masses- No blood- No Collapsed ampulla
Etiology a. Epigastric
errosiveb.Varises
Esophagusc. Peptic UlcerDiagnosis
Treatment
Planning maintenance
-Endoscopy
-Omeprazol- Sucralfat
- Bed Rest- Consume food that
not irritate gastric
Problem Solving1. Melena et causa Gastritis Erossiva• Anamnesis : Black tarry stool, abdominal pain, nausea and
vomitus, decreasing of apetite• PE : Pain on palpating epigastrium area , increasing bowel
movement on auscultation• PP : minimally increase of Cl, minimally decrease of HB,
decrease of HT • DD: Hematemesis Melena ec Varises Esophagus• Diagnose Plan : Endoscopy• R/Th : • Inj Omeprazole 1x40 mg• Syr Sucralfat 3 X 1C
Resume• Patients was having black tarry stool since a day ago with a liquid
consistency since 2 days ago for about 100 cc every bowel elimination. Patients Bowel elimination was about three times a day. The patients also having chronic abdominal pain for 20 years at the upper abdomen, Patients vomit once a day without blood. Patients had reduced appetite since 2 days ago. No History of having long term use of NSAID. The patient used to have antacid to reduce the abdominal pain
• Physical examination shows pain at palpating epigastrium area and increasing bowel movement
• Labs shows minimally increase of Cl, minimally decrease of HB, decrease of HT
Prognosis
• Quo ad Vitam : Dubia ad bonam • Quo ad Functionam : Dubia ad bonam• Quo ad Sanationam : Dubia ad bonam