Hematemesis Melena e.c. Gastritis Erosif with AKI and Hypertension grade.

II
Annisa Juwita 030.07.027

Name Age

Mr. T
61 y.0 Male

Identity

Sex
Address Occupation Religion

Galur-Cikampek , Karawang Labor

moeslem
Sundanese

Marital status Married Race

Education Date of admission Taken from

Elementary school
February 1st , 2012

Rengasdeklok

Anamnesis

Main complaint
Additional complaint

Vomiting of blood , color is black 3 times/day since 1 day before admitted to hospital with black and tarry stools 3 times/day .

Epigastric pain Nausea Malaise Shortness of breath

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. The amount of vomit is 250 cc, consist of blood together with water and food. Patient complaint about black and tarry stools 3 times since 1 day before hospitalized, thick consistency, no pain. He admitted he often consumed jamu putri sakti and AINS from drug stall to cure rheumatic for the last 2 months. Consuming alcohol denied.

History of present illness

He also complaint about epigastrium pain, nausea, malaise, and shortness of breath when doing activities, and feel more comfortable sleeping with 2 pillows. Mixi is normal, no blood. Dizziness, cold, cough, chest pain are denied.

History of past illness

Patient never had same symptom before Hypertension (+) since 25 years ago

DM (-)

Food and drugs allergy (-)

Asthma (-)

Family history
Same illness before (-)

Hypertension (+)

Asthma (+)

Food and drugs allergy (-)

DM (-)

Medication history

patient went to clinic, consume some drugs, but no improvement.

Habits history

Patient often consumed jamu putri sakti and AINS from drug stall to cure rheumatic. Drinking alcohol denied

General condition
General appearance
Moderately ill

conciousness
Compos mentis

Height
168 cm

Weight
70 kg

BMI 24,8

Vital signs

BP: 180/100 mmHg

Pulse: 70 times/minute

RR: 20 times/minute

Temp : 36,6 C

Physical examination

Head Eyes

Normocephali

Anemic conjunctiva +/+,

Icteric sclera -/ Lip: cyanosis(-) pallor(-) Pharynx: hyperemic (-), symmetrical, uvula at midline

Mouth
Neck

Lymph gland is not palpable Thyroid gland is not palpable

Thorax examination

Abdominal examination
Inspection distended brown skin skin abnormality (-)

Palpation Pain in epigastrium regio Hepatomegali (-) splenomegali (-)

Percussion Tymphani in all of his abdomen Shifting dullness (-)

Auscultation Bowel sound (+) normal

Extremity examination
Warm acrals
+ + + +

Oedem

Laboratory examination
February 1st 2012 Patient result Hb Leukocyte Trombocyte Ht Differential counting : -Basofil -Eosinofil -Batang -Segmen -Limfosit -Monosit GDS/reduction Ureum Creatinin 9,2 g% 8700/uL 201.000 30 % 0% 0% 0% 83 % 15 % 2% 74 mg/dl 124 mg/dl 2,39 mg/dl Normal range 12 17 g% 5000-10.000/uL 150.000-450.000 37-48 % (0-1)% (1-3)% (2-6)% (40-7)% (20-40)% (2-8)% 80-140 mg/dl 10-45 mg/dl 0.4-1.5 mg/dl

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

X - ray
CTR > 50% Cardiomegaly

Resume
Symptoms Vomiting of blood , color black 3 times/day since 1 day before admitted to hospital. Black and tarry stools 3 times/day Abdominal pain Nausea Malaise Shortness of breath Consumed jamu and AINS for the last 2 months History of hypertension Signs Vital sign : BP : 180/100 mmHg HR : 70 x/ minute RR : 20 x/ minute Temp : 36,6 C Anemic conjunctiva +/+ Palpation: pain in epigastrium regio Laboratory and other Hb : 9,2 g% Ht : 30% Ureum : 124 mg/dl Creatinin : 2,39 mg/dl

Differential diagnosis
Hemetemesis melena et causa Hypertension Portal Hematemesis melena et causa Hepatitis B Hematemesis melena et causa Varises Esophagus Hematemesis melena et causa Cirrhosis hepatis

Working Diagnosis
Hematemesis melena et causa Gastritis Erosif Acute Kidney Injury Hypertension grade II

Suggested examination
HBeAg, anti Hbe, anti HCV Electrocardiography

Urinalisa
Ultrasonography hepar Phisiology hepar ( albumin, globulin, GGT) Electrolit

Treatment
Bed rest NaCl 30 dpm i.v Ranitidin 2x1 Ondancentron 3x1 Pantoprazol 1x1 fl Kalnex 3x1 Impepsa syrup 4xC1 Captopril 3x12,5mg

Prognosis
Ad vitam Ad fungsionam Ad sanationam : ad bonam : dubia ad bonam : dubia ad bonam

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