AUTHOR : FRANSISKA SEPDAHLIA NIM : I11109058 LECTURE : DR. HILMI KURNIAWAN RISKAWA, Sp.A, M.Kes DATE / DAY : 14 JULY 2015 / THURSDAY

AUTHOR : FRANSISKA SEPDAHLIANIM : I11109058LECTURE: DR. HILMI KURNIAWAN RISKAWA, Sp.A, M.KesDATE / DAY: 14 JULY 2015 / TUESDAY

CASE REPORT ACUTE GASTRITIS (K29.70) + MODERATE MALNUTRITION (E44) + ANEMIA EC INFECTION (D55.2)

Identity

TDS, an child 11 years old, was care in Dahlia Room, Kartika Husada Hospital, for 2 days, From June 19, 2015 until June 20, 2015.

Chief Complain

Vomiting

History of Presenting Complaint

15 hour before hospitalized

Patient present with vomiting more than 10 times as much as 3 tablespoons each time vomit, not proyectile, in the form of a yellowish color foods that are not accompanied by the presence of blood or worms.

Complaints vomiting accompanied by pain in the regio of epigastrium that feels like a stabbing. Pain is not reffered to other regio of abdomen. Pain is not accompanied by bloating, belching and a burning sensation in the chest.

There is no fever, there is no seizure, there is no loss of consciousness.

Patient still want to eat and drink. The last voiding is 1 hour after vomiting.

Other complaints such as severe headache, painful swallowing, diarrhea, lower right abdominal pain, back pain, cough or colds denied by the patient. Defecation and urination are within normal limits.

Approximately 9 hours before the vomiting, patient dawn with food such as rice, fried chicken and drinking water, other additional food is not there, then the patient fasting. Because the patient vomit complaint was brought to the emergency room (ER) Kartika Husada Hospital and advised to be hospitalized. Complaints reduced after treatment from the hospital.

Patient has never experienced similar complaints before.

There is no family member who experienced a similar complaint with the patient.

Vaccination: As schedule

History of growth and development is appropriate with any normal children

Patient did not smoke and drink alcohol.

Patient has a habit of eating snacks outside almost every day.

Patient rarely wash their hands before eating.

Patient often late meal.

Physical Examination

General appearance: mild sick

Awarness: Compos mentis

Antropometry

Weight: 27 kg

Height: 140 cm

Height/age: 0 up to -1 SD

Body mass index/ age: -2 up to -3 SD

Nutrition state: Wasted (moderate

malnutrition)

Vital sign

Blood pressure: 120/80 mmHg

Heart rate: 117 x/s, reguler, strong in palpable

Respiratory Rate: 72x/s, reguler in rythm, thoracoabdominal type

Temperature: 37,2o C

Head: symmetric, tenderness (-), mass (-).

Eye: Conjungtiva anemis (-/-) , sclera ikterik (-/-), sunken eye (-/-), pupil isokor diameter 3 mm/3mm, direct light reflex (+/+), indirect light reflex (-/-).

Ear : secret (-), tenderness (-)

Nose : Nostril breathing(-), Concha hypertrofi(-),

secret (-).

Mouth and throat: dry lips and mucosa (-), pharynx hyperemis

(-), Tonsil T1/T1.

Neck : suprasternal retraction (-), enlargement of

lymp nodes (-), enlargement of thyroid

glands (-).

Generalist Status

Lung:Breath sounds basic : Vesiculer(+/+), rhonki (-/-), wheezing (-/-).Heart:Heart sounds S1-S2 reguler, murmur(-), gallop (-)Abdomen:Inspection : looks flat, venectation (-), mass (-)Auscultation : bowel sounds 4 6 x/minPercussion : tympani in all of field abdomenPalpation : Tenderness in the epigastric region (+), Hepar and Lymph are not palpable, mass (-)Anus and Genitalia:There is no abnormality.Extremity:Warm akral, capillary refill time (CRT) < 2 s. sianosis (-)Skin:Colour of skin is brown, icteric (-), petechie (-), rash (-), hematom (-).

Blood Test on June 19, 2015

June 19, 2015NormalLeukosit18.900 / mm34000-10.500 /mm3Eritrosit5,23 juta3,50 5,50 jutaHemoglobin12.7 g/dl12,5-16,1 g/dlHematokrit40.1 %36-47%Trombosit279.000 /mm3150.000 400.000 /mm3MCV76.7 fl78-95 flMCH24.2 pg26-32 pgMCHC31.6 %32-36%Limfosit %8.6 %15-50%Granulosit %87.2 %35- 80%

Diferential Diagnose

Acute Gastritis + moderate malnutrition.

Peptic ulcer + moderate malnutrition.

Acute gastritis (K29.70) + moderate malnutrition (E44)

Working Diagnose

Treatment

General ManagementDiet: Weight 27 kg, 1640 kkal Carbohydrat: 902 kkal Fat: 492 kkal Protein : 246 kkal Avoid spicy and acidic food.Special Management Intra vena fluid drainage Ringer Lactat (RL) 20 drops per minute Ampicillin 4 x 1 gram intravena Ondansentron 3 x 3 mg intravena Omeprazole 1 x 24 mg intravena

Follow up

Subjective

June 19, 2015

Entry day care

June20, 2015

Day care-2

Vomiting (-), appetite (+) good, drink (+) good.

Pain in the region of epigastric (+)

Pain in the epigastric region is reduced, no vomiting.

14

Objective

Vital sign

TemperatureJune 19, 2015June 20, 201536.70000000000000336.300000000000004heart rateJune 19, 2015June 20, 20158478respiratory rateJune 19, 2015June 20, 20152018Blood Pressure SystolicJune 19, 2015June 20, 2015120120Blood Pressure DiastolicJune 19, 2015June 20, 20158080

Objective

June 19, 2015

Entry day care

June 20, 2015

Day care-2

Tenderness in the epigastric region (+)

There are no tenderness in the epigastric region.

20 Juni 2015(Pukul 11.21 WIB)NormalLeukosit5.600 / mm34000-10.500 /mm3Eritrosit4,29 juta3,50 5,50 jutaHemoglobin10.5 g/dl12,5-16,1 g/dlHematokrit31.9 %36-47%Trombosit223.000 /mm3150.000 400.000 /mm3MCV74.3 fl78-95 flMCH24.6 pg26-32 pgMCHC33.1 %32-36%Limfosit %41.1 %15-50%Granulosit %55.1 %35- 80%Mentzer index : 17.31

Diferential diagnose:

Acute gastritis + Moderate malnutrition + Anemia ec infection.

Acute gastritis + Moderate malnutrition + Anemia ec iron deficiency.

Plan: Proofing Ferritin serum and total iron binding capacity Limitations inspection tool.

16

BACK HOME

Amoxicilin tab 3 x 500 mg

Syrup for gastric (in 5 mL Mg trisilicate 325 mg, Al(OH)3 colloidal 325 mg, simethicone 25 mg ) 3 x 2 tablespoon before meal.

FINAL DIAGNOSE

ACUTE GASTRITIS (K29.70) + MODERATE MALNUTRITION (E44)+ ANEMIA EC INFECTION (D55.2)

Discussion

Problem of case

Diagnose

Treatment

Prognose

How to diagnose of acute gastritis?

PATIENT

SIGN AND SYMPTOM

Vomiting

Pain in the region of epigastric

Tenderness in the region of epigastric

ACUTE GASTRITIS4,5,6

Asymptomatic

Patient often wake up at night

Pain in the region of epigastric

Vomiting

Tenderness in the region of epigastric

4.Fardah A, et al. Kuliah: Infeksi Helicobacter pylori pada anak. FK Unair RSU Dr. Soetomo Surabaya. Divisi Gastroenterologi Bagian Ilmu Kesehatan Anak. FK UNAIR. 2006. Hal 1 17.

5. Giacomo CD. Helicobacter pylori Gastritis and Peptic Ulcer Disease. Dalam: Guandalini S. Textbook of Pediatric Gastroenterology and Nutrition. London and New York. Taylor & Francis. 2004. Hal. 73 90.

6. Blanchard SS & Czinn SP. Peptic Ulcer Disease in Children. Dalam : Kliegman RM, et al. Nelson Textbook of Pediatrics. 19th edition. Philadelphia. Elsevier. 2011. Hal 1291 1293.

Leucocyte June 19, 2015 18.900/mm3

Etiology of Gastritis >>> Helicobacter pylori.5

Inflamation process from Helicobacter pylori can make leucocytosis.7

5. Giacomo CD. Helicobacter pylori Gastritis and Peptic Ulcer Disease. Dalam: Guandalini S. Textbook of Pediatric Gastroenterology and Nutrition. London and New York. Taylor & Francis. 2004. Hal. 73 90.

7. Jafarzadeh A, Akbarpoor V, Nabizadeh M, Nemati M and Rezayati MT. Total Leukocyte Counts and Neutrophil-Lymphocyte Count Ratio Among Helicobacter pylori Infected Patients With Peptic Ulcer : Independent of Bacterial Cag-A Status. Southeast Asian J Trop Med Public Health. 2013: 44(1); 82 88.

Diagnostic Helicobacter pylori

Non-invasive

invasive

IMT/Age -2 up to -3 SD

According to the calculation of anthropometric, Based on body weight per length, the patient include in wasting category, and based on clinical appearance it is suitable. Its mean that the patient suitable for moderate malnutrition criterias.

Jurnal Environmental Research and Public said that malnutrition by Helicobacter pylori caused by modification of pH in the gaster that can interfere with the absorption of some vitamins and mineral.10

10. Rodriguez L, Cervantes E & Ortiz R. Malnutrition and gastrointestinal and respiratory infections in children: a public health problem. International Journal of Environmental Research and Public Health. 2011;8:1174-1205.

ANEMIA

On 20 June 2015 found that the patient hemoglobin value was 10,5 g/dl. Standard normal hemoglobin children 11 years old is 12.5 to 16.1 g/dl. So the patient can be said, have anemia

Anemia normochrom microcytic.

Acute infection

ANEMIA

Inflamation process reduced iron concentration in circulation.11,12

11. Roy CN. Anemia of Inflammation. American Sociey of Hematology. 2010; 276 280.

12. Weiss G, Goodnough LT. Anemia of Chronic Disease. New England Journal of Medicine. 2005: 352(10); 1011 1023.

TREATMENT

TreatmentFunctionGeneralDiet :Weight 27 kg, 1640 kkalPatient nutritional needs. Carbohydrat : 902 kkal Fat : 246 kkal Protein : 492 kkalSpecialAmpicillinAmpicillin and Omeprazole first line drugs for gastritis (recommendation from North America Society of Pediatric, Gastroenterology, Hepatology and Nutrition). OmeprazoleOndansentronEffective for reduce vomiting.IVFD RLCrystalloid solution isotonis, it can used for substitute lost body fluid, facilitate administration of the drug by intravenous injection.

Prognose

Complication of gastritis :

Athropy gaster

Intestine metaplasia

Dysplasia and carcinoma of gaster

Adequate treatment and good lifestyle can prevent recurrence.

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