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  • Acute Gastritis: By: Muhammad Sidiq, MD

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    This document summarizes a case study of an 18-year-old female patient admitted to the emergency department with complaints of nausea and vomiting for 4 days. Her symptoms included stomach pain in the upper middle part, weakness, and loss of appetite. On examination, she appeared weak with epigastric tenderness. Laboratory tests showed normal hemoglobin, leukocyte, and platelet counts, and a negative COVID-19 rapid antigen test. She was diagnosed with acute gastritis and treated intravenously with fluids, omeprazole, ondansetron, and sucralfate syrup.

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    Dyspepsia Guntur

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    This document summarizes a case study of an 18-year-old female patient admitted to the emergency department with complaints of nausea and vomiting for 4 days. Her symptoms included stomach pain in the upper middle part, weakness, and loss of appetite. On examination, she appeared weak with epigastric tenderness. Laboratory tests showed normal hemoglobin, leukocyte, and platelet counts, and a negative COVID-19 rapid antigen test. She was diagnosed with acute gastritis and treated intravenously with fluids, omeprazole, ondansetron, and sucralfate syrup.

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    2 views11 pages

    Acute Gastritis: By: Muhammad Sidiq, MD

    Uploaded by

    dianarahimm
    This document summarizes a case study of an 18-year-old female patient admitted to the emergency department with complaints of nausea and vomiting for 4 days. Her symptoms included stomach pain in the upper middle part, weakness, and loss of appetite. On examination, she appeared weak with epigastric tenderness. Laboratory tests showed normal hemoglobin, leukocyte, and platelet counts, and a negative COVID-19 rapid antigen test. She was diagnosed with acute gastritis and treated intravenously with fluids, omeprazole, ondansetron, and sucralfate syrup.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 11

    Acute Gastritis

    By :
    Muhammad Sidiq, MD

    Supervisor :
    M. Diana Rahim, MD

    Indonesian Doctor Internship Program


    Guntur Hospital Garut
    October 2021
    Patient’s Identity

    Name: Mrs. AT
    Age : 18 years old
    Gender : Female
    Medical Record Number: 171365
    Admission Date : October,01 2021
    Time : 00.30
    GP : Eva, MD
    HISTORY TAKING

    Chief complain : Nausea and Vomiting

    The patient came to the emergency departement at Guntur Hospital with chief complain Nause and
    vomiting since 4 days before, oftenly she just vomited fluid likes saliva or small amount of food. She
    took medication which she got from clinic, but she forgot kind of medication for relieving her complaint.
    Unfortunatly the medication didn’t relieve her complain. When she came to ER, she feel nausea and
    vomitin, stomachache, especially part of upper middle, and she felt weak and loss appetite also.
    Sometimes she got uncomfartable when she breath because his illness.
    Fever, chest pain, diarrhea, bleeding, black stool was denied by patient
    HISTORY TAKING

    History of past illness:


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

    General Condition : Weak,


    Awareness : Composmentis
    GCS : E4M6V5
    Blood Pressure : 116/90
    Pulse Rate : 102x/menit
    Respiratory Rate : 20x/menit
    Temperature : 36.4 C
    Oxygen Saturation : 98% 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:
    • Hemoglobin : 14,5 gr %
    • Leucocyte : 8.100 /mm2
    • Hematocrite : 43,8 %
    • Thrombocyte : 443.000/mm3

    – Immunology :
    • Rapid antigen Covid-19 : Negative
    DIAGNOSE

    • Gastritis akut
    MANAGEMENT

    • IVFD Asering 20tpm


    • Inj Omeprazol 1x40mg
    • Inj Ondansteron 2x4mg
    • Sucralfat Syr 3x2C

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