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Gastro Esophageal
Reflux Disease(GERD)
Guiding lecturer : Dr. Irwin Sp.PD
By: Noor Ain bt Mohd Hariri
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Name: Mrs. E
Age: 40 years old
Address: DesaCengkong,KecPurwasan
Occupation:Housewife
Religion: Islam
Ethnic: Sunda
Marital Status: Married
Date of admission:
October 6th 2012
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Clinical history
Chiefcomplaint
Burning-painespecially on
upper
stomach
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Additional
complaint
Heartburn
Nausea
Regurgitation
Loss of appetitesHeadache
Muscle weakness
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Mrs E come to the emergency
unit,Hospital Karawang on Saturday night,6thOctober 2012 because of burning pain in her
stomach.Besides,shes feeling weak and fatigue.
She started feeling weak 2 days
before,without any cause.From that point,shestarted to loss her appetite.On Thursday she
drank coconut water,ate mungbean soup and ate
a lot of green,unripe mangoes.
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On Friday however,her stomach started
feeling burning-pain,especially on upperstomach.She had diarrhea twice.She felt extremely
weak after that, and her head hurts especially on
the forehead.She also feeling nausea and vomiting
water.On that instance she felt heartburn andfeeling regurgitation in her throat and behind her
nose.
The burning sensation only presence after
she ate and last a few minutes.Afraid that she
might throw up,she ate only 2 spoons of porridge
on Friday and ate nothing on Saturday.
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After admitted in the ward,
she never diarrhea,
vomiting,and only have
mild burning pain andheadache. Overall,her
condition becomes better
and she regain her
appetite.
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Same illness
(+)
Hipertension
(-)
DiabetesMellitus
(-)
Allergy
(-)
Asthma
(-)GI Disease
(-)
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Samesymptom(-)
Hypertension(unknown)
DiabetesMellitus(unknown)
Allergy
(-)
GI disease
(-)
Asthma
(-)
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Always eatingfruits & vegie
Seldomexcercise
Never consumedrugs
Alwaysconsume herbal
supplement
Never drink ¬ a smoker
Loves eatingsour food
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She does not taking anydrugs to relieve her
pain.Going to the hospital is
her first attempt to cure her
illness.
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General appearance : Mildly ill
Conciousness : Compos mentis
Vitalsign
BP :110/80mmHg
Temperature:
36,2C
RR: 16x/m Pulse: 80x/m
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NormocephaliHead
Normotia, secrete-/-, serumen-/-
Eyes
Ears
Nose
Mouth
Throat Lymph nodules not palpable, tiroid gland
not palpable, JVP 5+2 cm H20Neck
Pupil isokor, CA -/-, SI -/-
septum deviation (-), secrete -/-, concha normal,
mucosa not hyperemic
dry mouth (-),normal papil,mucosa hyperemic (-),
teeth caries (-)
Tonsils T1/T1 pharynx hyperemic (-)
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Inspection : Symmetrical
Palpation : Equal vocal fremitus
Percussion : Sonor
Auscultation : Vesicular breath sound in
both lung, no ronchi and wheezing
Lung
Inspection : Ictus cordis is invisible
Palpation : Ictus cordis is palpable at 5th
ICS LMCS
Percussion : No enlargement of the heart
Auscultation: Regular I - II heart sound nomurmur and gallop
Heart
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caput medusa(-), smilingumbilicus (-)
Inspection
Palpation
No pain present on abdominalpercussion
Sounds tympanyPercussion
Bowel sound (+)Auscultation
Pain present on palpation at allabdominal region, esp. Epigastric
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Warmacrals
+ +
+ +
- -
- -
Edema
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August 6th 2012 Patient result Normal range
Hb 10,5 g% 12 17 g%
Leukocyte 6,400/uL 5000-10.000/uL
Trombocyte 171.000 150.000-450.000
Ht 32 % 37-48 %
GDS 71 mg/dl 80-140 mg/dl
Ureum 21,9 mg/dl 10-45 mg/dl
Creatinine 0,82 mg/dl 0.4-1.5 mg/dl
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August 7th 2012 Patient result Normal range
GDS 108 mg/dl 80-140 mg/dl
August 8th 2012 Patient result Normal range
GDS 124 mg/dl 80-140 mg/dl
August 9th 2012 Patient result Normal range
GDS 133 mg/dl 80-140 mg/dl
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Symptoms Signs Laboratory
and othersBurning-pain
especially on upper
stomachHeartburn
Nausea
Regurgitation
Loss of appetites
Headache
Muscle weakness
Pain present on
palpation at all abdomenregion especially
Epigastric
Hb 10,5 g%
Ht 32 %
GDS 71 mg/dl
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AchalasiaStenosis esophagus
Gastritis
Tumour esophagus
Duodenum ulcer
Peptic ulcer
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Esofagographywith barium Endoscopy
Ambulatoryacid (pH)
probe tests
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Dextrose 5% 20d/m
Omeprazole 2x1
Mucoguard 3x1 CthFucoidan 1x1
Avoid sour,spicy,fatty foods
Eat meals in small portions
Dont lie down after eating
Elevate bed
Medications
Non-medications
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Ad vitam
Ad bonam
Ad sanationam
Dubia ad bonam
Ad fungsionam
Ad bonam
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