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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 &not 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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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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