Anemia Gravis ec Susp Gatropathy erosive

By :
Muhammad Sidiq, MD

Supervisor :
M. Diana Rahim, MD

Indonesian Doctor Internship Program

Guntur Hospital Garut
October 2021
Patient’s Identity

Name: Mrs. EK
Age : 57 years old
Gender : Female
Medical Record Number: 171514
Admission Date : October,04 2021
Time : 15.00
GP : Emil, MD
HISTORY TAKING

Chief complain : Nausea and Vomiting black fluid

The patient came to the emergency departement at Guntur Hospital with chief complain
Nause and vomiting one days before come to ER, it was 5 times a day, she vomit black
fluid, which looks like blood, and black stool likes oil yesterday. She took medication such
as promagh for relieving her complaint, but she did’t get better. When she came to ER, she
didn’t feel nausea and vomiting either. She just felt weak and slightly loss appetite.
Heartburn, fever, chest pain, diarrhea, short breathness, reffered pain was denied by patient.
HISTORY TAKING

History of past illness:

She has h/o similar illness (several years ago)
She has h/o chronic magh
No h/o allergy -
No h/o TB, Asthma, Hypertension, diabetic
Physical Examination

General Condition : Weak, pale

Awareness : Composmentis
GCS : E4M6V5
Blood Pressure : 130/90
Pulse Rate : 107x/menit
Respiratory Rate : 20x/menit
Temperature : 36.3 C
Oxygen Saturation : 96% free air
Physical Examination

Head : normochepal
Eyes : Anemic Conjungtiva +/+, Icteric Sclera - / -,

Nose : nostring breathing ( - ), rhinorrhea -

Mouth: cyanosis ( - ), tonsil T1/T1, Pharyng hiperemis -

Neck : lymph node enlargment ( - )

Thorax : symmetrical chest movements
Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : VBS right = left, crackle - / -, wheezing - / -

Abdomen : flat, soepel, bowel sound ( + ) normal, epigastric tenderness -

Liver : within normal limits
Spleen : within normal limits

Extremities :
Warm, Edema (-), CRT < 2 second

Skin : cyanosis -, rash -

Supporting Examination

• LABORATORY EXAMINATION RESULT

– Blood Routine: – Blood chemistry:

• Hemoglobin : 6,4 gr % • Random Blood sugar: 133

• Leucocyte : 9.800 /mm2 • Ureum : 34

• Hematocrite : 24,1 % • Creatinin : 0,79 mg/dl
• Thrombocyte : 444.000/mm3 • OT/PT :33/29
– Immunology :
• Rapid antigen Covid-19 : Negative
DIAGNOSE

• Anemia Gravis susp gastrophaty erosiva

MANAGEMENT

• IVFD NaCl 10tpm

• Inj Omeprazol 1x40mg
• Inj Ondansteron 2x4mg
• Inj Kalnex 3x1
• Inj Vit K 3x1
• Sucralfat Syr 3x2C
• Amiodaran 1x100mg