DUTY REPORT APRIL 6 TH 2016 APPROACHES TO UNINVESTIGATED DYSPEPSIA PPDS on duty : dr. Pradipto, dr. Irfan Coass on duty : Nadhira, Pinta, Eka Supervisor dr Soroy Lardo SpPD FINASIM Fakultas Kedokteran Universitas Indonesia Divisi Penyakit Tropik dan Infeksi Departemen Penyakit Dalam RSPAD Gatot Soebroto
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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
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