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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