DUTY REPORT Melena et causa Gastritis Erossiva Hypertension Supervisor : Dr. dr. Soroy Lardo, SpPD FINASIM Johanes Hansen Yuwen Fondly Hulkyawar Division of Infectious and Tropical Diseases Indonesia Army Central Hospital Gatot Soebroto Faculty of Medicine UKRIDA
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Melena et Causa Gastritis Erosiva and Hypertension
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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
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