DUTY REPORTAPRIL 6TH 2016

APPROACHES TO UNINVESTIGATED DYSPEPSIA

PPDS on duty : dr. Pradipto, dr. IrfanCoass on duty : Nadhira, Pinta, EkaSupervisor dr Soroy Lardo SpPD FINASIMFakultas Kedokteran Universitas IndonesiaDivisi Penyakit Tropik dan Infeksi Departemen Penyakit DalamRSPAD Gatot Soebroto

PATIENT RECAPITULATION

1. Mrs. RA 31 y.o. febris D+5 susp DHF2. Mr. HA 69 y.o. loss of consciousness3. Mr. BA 52 y.o. abdominal pain4. Mrs. ER 28 y.o. febris + urticaria susp viral

infection5. Mrs. RE 27 y.o. diarrhea6. Mrs. SU 48 y.o. dyspepsia

PATIENT’S IDENTITY• Name : S• Sex : Female• Age : 48 years old• Job : Housewife• Religion : Moslem• Marital Status : Married• Address : West Pademangan

ANAMNESIS• Autoanamnesa on 7/4/16 at 2 AM

• Chief Complain :Nausea since 1 day prior to admission

• Additional Complain : -

PRESENT ILLNESS• The patient complained of having nausea since 1 day prior to

admission. It was also accompanied with epigastric pain since 1 day prior to admission, with VAS 7/10. There was no worsening or improvement on the scale of the pain by changing position or eating meals. She denied of having heartburn or bitter taste in mouth.

• She also vomited more than 5 times, containing food and yellowish fluid since 1 day prior to admission. There were no history of fever, cough, blood-contained vomit, and bloody diarrhea.

• There was lost of appetite resulting in decrease intake and rehydration. There were no urination and defecation problem reported.

• There was no history of NSAID use.

PRESENT ILLNESS• She complained of having weight loss (+/- 7kgs) since 1 month prior

to admission. She was admitted with the same symptoms 1 month ago. There was no complaint of pain or difficulty in swallowing, history of any gastric/duodenal malignancy, intraabdominal mass, or lymphadenopathy.

• She denied of having hypertension, DM, heart problem, allergy, asthma.

PAST ILLNESS• There was past history of having the same symptoms and

admitted to Sulianti Saroso Hospital 1 month ago.• There was no history of any surgery.

• No family member with the same symptom• HT – • DM – • Asthma -

FAMILY ILLNESS

SOCIAL, HABIT, AND LIFESTYLE• She is married and currently has two kids.• She is a housewife.• She has no habit of drinking soda, alcohol, tea, coffee, or

sour food. She likes eating spicy meals.• Smoking (-), alcoholic (-), IVDU (-), promiscuity (-).

PHYSICAL EXAMINATIONVITAL SIGNS• General State : Moderately sick• Consciousness : Compos Mentis• Blood Pressure : 130/90 mmHg• Pulse : 88 x/minute, regular• Respiratory Rate : 20 x/minute, regular• Temperature : 36.5oC• Body Weight : 71 kg• Body Height : 155 cm• BMI : 29,5 (Obese grade I)

PHYSICAL EXAMINATIONGeneral Examination• Head : Normocephal

• Eye : anemic conjunctiva (-/-), icteric sclera (-/-)• Ears : normotia, discharge (-)• Nose : septum deviation (-), discharge (-)• Mouth : hyperemic pharynx (-)

• Neck : JVP 5-2 cmH2O lymph nodes enlargement (-)

• Thorax : symmetric, intercostal retraction (-)• Cor : regular 1st and 2nd heart sound, murmur (-), gallop (-) • Pulmo : vesicular breathing sounds, rales (-/-), wheezing (-/-)

• Abdomen : • I: flat, not distended, caput medusa (-)• A: bowel sound 4x/minute• P: no enlargement of liver & lien, epigastric tenderness (+), McBurney (-)• P: timpani, shifting dullness (-)

• Extremities : warm, pitting edema (-), cyanosis (-) CRT < 2 seconds

DIAGNOSTIC PLANS

RESULT NORMAL RANGE

Daily hematology:

Hb 14.6 13 - 18 g/dl

Ht 42 40 – 52 %

Erythrocyte 5.1 4.3 - 6.0 mil /ul

Leukocyte 7350 4800 - 10800/ul

Thrombocyte 284000 150000 - 400000/ul

MCV 83 80 – 96 fL

MCH 29 27 - 32 pg

MCHC 35 32 – 36 g/dL

LAB EXAM (6/4/16)

RESULT NORMAL RANGE

Ur 24 20-50 mg/dL

Cr 1.0 0.5-1.5 mg/dL

GDS 96 <140 mg/dL

Electrolyte :

Na 135 135 – 147 mmol/L

K 4.1 3.5 – 5.0 mmol/L

Cl 103 95 – 105 mmol/L

RESUMEThe patient, female, 48 y.o., complained of having

nausea since 1 day prior to admission. Epigastric pain (+), vomiting (+) 5 times containing food, lost of appetite (+), weight loss (+) 7 kgs, past history of the same symptoms 1 month ago (+). Physical exams revealed epigastric tenderness (+). Lab exam revealed no abnormal findings.

PROBLEM LIST• Dyspepsia

ASSESSMENT1. Dyspepsia

Anamnesis: nausea, vomiting, lost of appetite, weight loss 7kgs in 1 month, past history of same symptoms 1 month agoPhysical examination: epigastric tenderness (+)

• The patient is considered of having organic dyspepsia dd functional dyspepsia. She had epigastric pain, which is one of the typical dyspepsia clinical manifestation according to ROME III.

• There was complaint of having weight loss 7 kgs in a month, which is one of the alarm sign of uninvestigated dyspepsia. It is most likely an organic dyspepsia, and the patient should be considered to undergo endoscopic exam (ACG).

• The symptoms didn’t last for 3 months, or at least 6 months prior to diagnosis, so it is less likely for the patient to have functional dyspepsia. However, it can’t be ruled out yet.

Approaches to Uninvestigated Dyspepsia

• Diagnostic Plan- Endoscopic procedure

• Therapeutic PlanIVFD NaCl0,9% 500cc/8 hours Diet: soft food 1700 kcal/dayOmeprazole 1 x 40 mg IV

• Education Plan- Avoid foods or drinks that can trigger gastric acid

production (spicy or sour food, soda, coffee, tea, alcohol)

- Small frequent feeding

SUMMARY• Patient, 48 y.o., complained of having nausea since 1 day

prior to admission. The patient is currently diagnosed as dyspepsia. She is being treated with soft food 1700 kcal/day, IVFD NaCl 0,9% 500 cc/8 hours, and omeprazole 1x40 mg IV.

• Short term goals: • - eliminate symptoms (pain, nausea, vomiting)• - find the causal of dyspepsia

• Long term goal:• - prevent recurrent symptoms • - prevent complication

PROGNOSIS• Qua ad vitam : Bonam• Qua ad functionam : Dubia ad bonam• Qua ad sanationam : Dubia ad malam

THANK YOU