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