case sis melena

8/2/2019 Case sis Melena

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Hematemesis Melena e.c. Gastritis

Erosif with AKI and Hypertension

grade.IIAnnisa Juwita

030.07.027


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Identity

Mr. TName

61 y.0Age MaleSex

Galur-Cikampek , KarawangAddress

LaborOccupation

moeslemReligion

MarriedMarital status

SundaneseRace

Elementary schoolEducation

February 1st , 2012Date of admission

Rengasdeklok

Taken from


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Anamnesis

Vomiting of blood , color isblack 3 times/day since 1day before admitted tohospital with black and tarrystools 3 times/day .

Maincomplaint

Epigastric pain Nausea

Malaise Shortness of breath

Additional

complaint


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History of present illness Patient came to emergency room RSUD Karawang

with complaint vomiting of blood, color is black like

coffee 3 times since 1 day before hospitalized. Theamount of vomit is 250 cc, consist of blood togetherwith water and food.

Patient complaint about black and tarry stools 3

times since 1 day before hospitalized, thickconsistency, no pain. He admitted he often consumed jamu putri sakti

and AINS from drug stall to cure rheumatic for thelast 2 months. Consuming alcohol denied.


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History of present illness

He also complaint about epigastrium pain,nausea, malaise, and shortness of breath whendoing activities, and feel more comfortablesleeping with 2 pillows.

Mixi is normal, no blood.

Dizziness, cold, cough, chest pain are denied.


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History of past illness

Patient never hadsame symptom

before

Hypertension (+)since 25 years ago

DM (-)

Food and drugsallergy (-)

Asthma (-)


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Family history

Same illness before

(-)Hypertension (+) Asthma (+)

Food and drugsallergy (-)

DM (-)


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Medicationhistory

patient went to clinic, consume some drugs, but no

improvement.

Habitshistory

Patient often consumed jamu

putri sakti

and AINS

from drug stall to cure rheumatic. Drinking alcohol denied


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General conditionGeneral appearance

Moderately ill

conciousness

Compos mentisHeight

168 cm

Weight

70 kg

BMI

24,8


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Vital signs

Pulse:

70times/minute

Temp :36,6 C

RR:

20times/minute

BP:

180/100mmHg


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Physical examination

NormocephaliHeadAnemic conjunctiva +/+, Icteric sclera -/-Eyes Lip: cyanosis(-) pallor(-)

Pharynx: hyperemic (-), symmetrical,uvula at midlineMouth

Lymph gland is not palpable

Thyroid gland is not palpable

Neck


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Thorax examination


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Abdominal examination

Inspection

distended brown skin skin

abnormality(-)

Palpation

Pain inepigastriumregio

Hepatomegali

(-) splenomegali

(-)

Percussion

Tymphani inall of hisabdomen

Shifting

dullness (-)

Auscultation

Bowel sound(+) normal


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Extremity examination

Warm acrals

Oedem

+ +

+ +

- -

- -


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Laboratory examination

February 1st

2012 Patient result Normal rangeHb 9,2 g% 12 17 g%Leukocyte 8700/uL 5000-10.000/uLTrombocyte 201.000 150.000-450.000

Ht 30 % 37-48 %

Differential counting :-Basofil-Eosinofil-Batang-Segmen

-Limfosit-Monosit

0 %0 %0 %83 %

15 %2 %

(0-1)%(1-3)%(2-6)%

(40-7)%

(20-40)%(2-8)%

GDS/reduction 74 mg/dl 80-140 mg/dl

Ureum 124 mg/dl 10-45 mg/dlCreatinin 2,39 mg/dl 0.4-1.5 mg/dl


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GFR:

= (140- age) x weight x 0,85

72 x plasma creatinin

= (140-61) x 70 x 0,85

72 x 2, 39

= 27,3 mL/mnt/1,73m


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ResumeSymptoms Signs Laboratory and other

Vomiting of blood ,color black 3 times/daysince 1 day beforeadmitted to hospital.Black and tarry stools 3times/dayAbdominal pain

NauseaMalaiseShortness of breath Consumed jamu andAINS for the last 2months

History of hypertension

Vital sign :BP : 180/100 mmHgHR : 70 x/ minuteRR : 20 x/ minuteTemp : 36,6 C

Anemic conjunctiva

+/+Palpation: pain inepigastrium regio

Hb : 9,2 g%Ht : 30%

Ureum : 124 mg/dlCreatinin : 2,39 mg/dl


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Differential diagnosis

Hemetemesis melena et causa HypertensionPortal

Hematemesis melena et causa Hepatitis B

Hematemesis melena et causa VarisesEsophagus

Hematemesis melena et causa Cirrhosis hepatis


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Suggested examination

HBeAg, anti Hbe, anti HCV

Electrocardiography

Urinalisa

Ultrasonography hepar

Phisiology hepar ( albumin, globulin, GGT)

Electrolit


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Treatment

Bed rest

NaCl 30 dpm i.v

Ranitidin 2x1

Ondancentron 3x1

Pantoprazol 1x1 fl

Kalnex 3x1 Impepsa syrup 4xC1

Captopril 3x12,5mg


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Prognosis

Ad vitam : ad bonam

Ad fungsionam : dubia ad bonam

Ad sanationam : dubia ad bonam


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THANK YOU

case sis melena

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