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Case Report

Anemia e.c Haematemesis Melena
e.c Suspect Upper Gastrointestinal
Bleeding with Suspect Chronic
Kidney Disease
By :
Idham Andayana

Preceptors
Dr Hj. Ihsanil Husna Sp.PD

MEDICAL PROFESSION PROGRAMME DEPARTMENT OF INTERNAL MEDICINE
JAKARTA ISLAMIC HOSPITAL CEMPAKA PUTIH
FACULTY OF MEDICINE UNIVERSITY OF MUHAMMADIYAH JAKARTA
2018

A. PATIENT’S IDENTITY

A. PATIENT’S IDENTITY
• Name : Mr A
• Age : 60th years old
• Education : Junior High school
• Marital Status : Married
• Occupation : Parking Lot Keeper
• Religion : Moslem
• Date of Admission : April, 10th 2018
• MR Number : 00 98 34 32

B. ANAMNESIS (AUTOANAMNESIS)
• A. Chief Complaint :
Limp since ± 3 days ago before entering the
hospital
Another Complaint :
Nausea (+), Vomit (-), Dizzy (+), heartburn (+),
decreased appetite.

• B. History of Present Illness
• A Patient came to Jakarta Islamic Hospital of Cempaka Putih
Complained of limping for 3 days ago.
• The patient is also complained have 4 times vomited with a
dark red coloured vomit

• Patient denied the complaint preceded by a high fever. • Another complaint is a pain in the left upper part of abdomen followed by heartburn sensation and belching. • The patients do not have a sense of appetite. • Patient also complaint about paleness in the palm. face and the trunk of the body. dizziness (+). Patient does not have a problem in urinating . and nausea (+). ANAMNESIS • Mr A also confessed had a dark coloured faeces one time in 3 days ago. • Complaint of dyspnea and coughing are denied.

but the patients do not know the result of the examination and the proof was lost. • And patients admit that he once treated with dyalisis one year ago. ANAMNESIS • C. History of Past Illness • Mr.A had a history of the same complaint one year ago and had gone through endoscopy. • No history of Hypertension • No history of Diabetes Mellitus • No history of cardiovascular disease .

History of Allergy • Patient has no allergy to food. ANAMNESIS • D. drugs and weather . History in the family • None of his family has same problem • No history of Hypertension • No history of DM • No history of cardiovascular disease • E.

ANAMNESIS • F. History of treatment and medication • The patients has not treated this complaint before • The patients denied the use of orally anti inflammation drugs • G. History of Habits Smoking Habits : Yes Drinking Alcohol : Yes Doing Exercise : Denied .

PHYSICAL EXAMINATION • Generalized State: Mild ill • Consciusness : Composmentis • Vital Sign Blood Pressure : 100/70 mmHg Heart Rate : 90x/minute Respiratory Rate : 20x/minute Temperature : 36.Body weight : 50 kg .3 (Underweight) .BMI : 18. C.Body high : 165 cm .9 ° C • Anthropometric Status .

PHYSICAL EXAMINATION • GENERAL PHYSICAL EXAMINATION • Head : Normocephal. Secret (-/-). Cyanosis (-) • Neck : Palpable Mass (-). Lymphadenopathy (-) . • Mouth : The Oral Mucosa Moist. Icteric Sclera (-/-) • Nose : Epistaksis (-/-). Deviated Septum (-/-). Deformity (-) • Eyes : Anemic Conjungtiva (+/+).

PHYSICAL EXAMINATION • THORAX – LUNGS • Inspection : The movement of the chest symmetrical • Palpation : Same vocal fremitus in dextra et sinistra • Percussion : Sonor •Auscultacion : Vesicular breath sounds + / +. Wheezing . Ronkhi -/-. Gallop (-) ./ - – HEART Inspection : Ictus cordis seen in ICS V LMCS Palpation : Ictus cordis palpable ICS V LMCS Percussion : Right heart margin: Sternalis line sinistra ICS-V Left heart margin: Midclavicula line sinistra ICS-V. • Auscultation : Regular 1st & 2nd heart sounds. Murmur (-).

Warm acral (+ / +). Warm acral (+ / +). RCT <2 seconds (+ / +) Anemic (+/+) . darm contour (-) darm steifung (-) •Auscultation : Bowel Sound (+) 9x/minutes •Palpation : Epigastric Pain (+)./ -). scar (-). spleen enlargement (-) •Percussion : Tympanic in all abdominal fields • Extremities • Superior : Edema (. Hepar 1cm under arcus costae. RCT <2 seconds (+ / +) Anemic (+/+) • Inferior : Edema (-/ -). PHYSICAL EXAMINATION • Abdomen •Inspection : Convex.

80 – 5.7 – 15.440 Eritrocyte 1.0 MCV 75 fL 80-100 MCH 20 pg 26-30 MCHC 27 g/dL 32-36 Creatinine 2. LABORATORY EXAMINATION IN EMERGENCY ROOM EXAMINATION VALUE UNITS NORMAL Hemoglobin 2.14 103/uL 3.47 Trombocyte 499 103/uL 150 .1 mEq/L 3.50 – 5.3 g/dL 11.4 Na 139 mEq/L 135-147 GDS 97 gr/dL <200 .11 Hematocryte 9 % 35 .60 .6 mg/dL < 1.20 Kalium 5.5 Leukocyte 17.01 103/uL 3.

Palmar and . confessed had a dark .MCV : 75 anemis (+).01 coloured faeces one time in .14 epigastric pain.MCHC : 27 .6 . Conjunctiva .Hematocryte : 9% 3 days ago.Hemoglobin : 2. RESUME • Mr. • Laboratory Findings The patient is also had 4 . D. have an .A 60 years old came to • Vital Sign within normal Jakarta Islamic Hospital of limits Cempaka Putih Complained of limping since 3 days ago.Leukocyte : 17.3 times vomited with a dark gr/dL red coloured vomit.MCH : 20 plantar anemis (+) .Creatinine : 2.Erythrocyte : 1.

c Upper Gastrointestinal Bleeding with Chronic Kidney Injury Stage IV . E. PROBLEM LIST •Clinical Diagnosis o Anemia e.

Renal Ultrasonography bleeding that occurred . F.Guaiac Test .Endoscopy Treatment Room .Bed Rest .NGT for evaluation of .Radiologic Thorax X-Ray • Therapeutics : Imaging .Liver Function test • Non-Therapeutics : (SGOT/SGPT) .IVFD Crystaloid 20 gtt/m .Serial Complete Blood Count .Blood Transfusion (PRC) Target (HB>10gr/dL . PLANNING • Diagnostic : • Treatment wards :-Ordinary .Fasting until the cause .GFR Test .PPI .Hemoglobin Electrophoresis of bleeding known .

c Dexamethasone Inj (+) Pale (+) RR:21x/m Suspect Upper Ca Gluconate drip Nausea(+) HR:79x/m Gastrointestin PRC Transfusion 3flask Coughing (-) T:37.7 CaCO3 3x1 Kidney Omeprazole 2x1 Erithrocyte : Disease Hb serial 2.07 Haematocrite : 24% .9 milions Leukocyte : 17. G.c PRC Transfusion 2 flask (+) Pale(+) RR:20x/m Suspect Upper Ca Gluconate Nausea (-) HR:80x/m Gastrointestin Folic Acid 3x1 T:37.FOLLOW UP Date Subjective Objective Assesment Planning 11-04-2018 Limpness BP : 110/70 Anemia e. Omeprazole 2x1 Chronic Bronchitis 12-04-2018 Limpness BP : 110/70 Anemia e.2C al Bleeding CBC Serial Dyspnea (+) with Chronic Folic Acid 3x1 Thorax X-Ray Kidney B1B6 2x1 Result : Disease CaCO3 3x1 Cardiomegaly.0C al Bleeding B1B6 2x1 with Chronic Hb : 7.

1C Omeprazole 2x1 Konjunctiva slightly anemic (+) Hb : 11.0C examination .2 gr/dL 15-04-2018 Limpness BP : 110/70 Anemia e.2C Omeprazole 2x1 Hb serial Hb : 10.c Suspect Upper Folic Acid 3x1 (+) Pale (-) RR:20x/m Gastrointestinal Bleeding with B1B6 2x1 Nausea(-) HR:87x/m Chronic Kidney Disease CaCO3 3x1 T:37. FOLLOW UP Date Subjective Objective Assesment Planning 13-04-2018 Limpness BP : 110/70 Anemia e.9 gr/dL 14-04-2018 Limpness BP : 110/70 Anemia e.c Suspect Upper Patients Discharged and planned for (+) Pale (-) RR:20x/m Gastrointestinal Bleeding with further control and for endoscopic Nausea(-) HR:83x/m Chronic Kidney Disease examination and series of renal function T:37.c Suspect Upper Folic Acid 3x1 (+) Pale (+) RR:19x/m Gastrointestinal Bleeding with B1B6 2x1 Nausea(-) HR:77x/m Chronic Kidney Disease CaCO3 3x1 T:37.

LITERATURE REVIEW 1 UPPER GASTROINTESTINAL BLEEDING .

DEFINITION “Upper gastrointestinal bleeding (UGIB) is defined as bleeding derived from a source proximal to the ligament of Treitz” Anthony.S Fauci et al Harrison Principal of Internal Medicine 17th edition p : 1855-1871 New York . McGraw-Hill 2017 .

EPIDEMIOLOGY OF UGIB • Gastrointestinal bleeding is the most common cause of hospitalization due to gastrointestinal disease in the United States accounts for more than 507.000 • $4.85 billion in costs annually .

ETIOLOGY • Peptic Ulcer Disease • Portal Hypertension • Malorry-Weiss Tears • Vascular Anomalies • Gastric Neoplasm • Erosive Gastritis • Erosive Esophagitis .

ulcer disease. . DIAGNOSIS • ANAMNESIS – History findings include weakness. – Patients may have a history of dyspepsia (especially nocturnal symptoms). and NSAID or aspirin use. early satiety. and melena (black stools with a rotten odor). dizziness. syncope associated with hematemesis (coffee ground vomitus).

DIAGNOSIS • PHYSICAL EXAMINATION – Pallor may present associated with loss of blood – Vital sign should be measured In case of Shock – Signs of chronic liver disease should be noted. including spider angiomata. increased luneals. pedal edema. and asterixis . splenomegaly. gynecomastia. ascites.

and Coagulation – Esophagogastroduodenoscopy – Chest Radiography Examination – CT Scan – Angiography – Biopsy . BUN. DIAGNOSIS o DIAGNOSTIC FEATURES – Complete Blood Count – Type and Blood Crossmatch in case planned for transfusion – BMP.

TREATMENT • Medication – Eradication of H.pylori – Resuscitation In case of shock – Transfusion In case of severe blood lose • Surgery Intervention • Endoscopic clipping or sewing .

COMPLICATION • Anemia • Hypovolemic Shock • Chest Pain .

PROGNOSIS .

LITERATURE REVIEW 2 CHRONIC KIDNEY DISEASE .

DEFINITION “Chronic kidney disease (CKD) encompasses a spectrum of different pathophysiologic processes associated with abnormal kidney function. and a progressive decline in glomerular filtration rate (GFR)” .

PATHOPHYSIOLOGY OF CKD .

ETIOLOGY OF CKD .

CLASSIFICATION OF CKD .

DIAGNOSTIC APPROACH FOR CKD • Anamnesis • Physical Examination • Laboratory and other examinations findings – Urinalysis – Ultrasonography – Complete Blood Count – etc .

TREATMENT PLAN IN CKD  Delaying or halting the progression of CKD  Protein Restriction  Reducing Intraglomerular Hypertension and Proteinuria  Control Blood Glucose Level  Control Systemic Hypertension  Diagnosing and treating the pathologic manifestations of CKD  Timely planning for long-term renal replacement therapy .

Coronary Artery Disease III.Coagulopathy d. Disorders of Mineral Metabolism c. COMPLICATION OF CKD a.Heart Failure IV. Acid-Base Disorders f. Cardiovascular Complication I. Anemia II. Neurologic Complication g. Endocrine Disorders . Hypercalemia e.Pericarditis b. Haematologic Complications I. Hypertension II.

a low serum albumin. and malignancy. Other causes include infection. • Diabetes. cerebrovascular disease. but survival for as long as 25 years may be achieved depending on comorbidities. PROGNOSIS OF CKD • Survival rates on dialysis depend on the underlying disease process. • The most common cause of death is cardiac disease (more than 50%). advanced age. lower socioeconomic status. • Patients undergoing dialysis have an average life- expectancy of 3-5 years. and inadequate dialysis are all significant predictors of mortality .