ANEMIA GRAVIS EC MELENA EC GASTRITIS EROSIVE

By : CYNTHIA NATALIA 03007054

IDENTITY
Name Age Sex Education Occupation Religion Marital status Admitted Taken from : Mr. S : 51 years old : male : elementary school : Labour : Islam : Married : March 6th 2012 : Rengasdengklok

HISTORY TAKING
MAIN COMPLAINT Black excreta accompanied by blood, occurred since two days before hospitalized.

SIDE COMPLAINTS Fatigue Nausea Vomitus Epigastric pain Headache

HISTORY OF PRESENTING COMPLAINT

A patient came to Karawang City Hospitals Emergency Room (UGD RSUD Karawang) on March 6TH 2012 with chief complaints of black and bloody excrements that had occurred since two days before hospitalized. Defecation occurred two days daily, around 500 cc in amount, and its excrement black in color with soft consistency, devoid of roughness or liquid, and there were no phlegm detected. It had been two days since patient felt fatigue. Fatigue alowly increased and ended up disturbing his activities. Additionally, patient also suffered from excruciating stomachache as well as occasional, especially when patient consumes spicy or sour-flavored food.

Patient also suffered from nausea and regular vomiting. Vomiting took place three times a day, filled with bloodless ingested food, as well as headache. Headache is suffered specifically in the back of the head and nape area. Patient admits decrease in appetite, from three times of meal to two times of meal daily. Since the lost of appetite, patient felt his body weaken. Patient denies any fever, cold and coughing, shortness of breath, or blurry vision. Patients urine is yellow in color, fairly transparent, bloodless, and without he feeling of releasing sand. Urination occurred five times a day and painless. Patient does not take any blood supplement medication.

HISTORY OF PAST ILLNESS

SAME SYMPTOM BEFORE (-) DIABETES (-)

HYPERTENSION (-)

ASTHMA (-)

KIDNEY DISEASE (-)

Gastritis ( +)

FAMILY HISTORY

SAME DISEASE (-)

HYPERTENSION (-)

DIABETES (-)

KIDNEY DISEASE (-)

ASTHMA (-)

Personal & Social History

Patient often consumed spicy and sour food. Patient also consumed medications purchased from common stalls to relieve the headache. patients were has a history of drinking traditional herbal medicine for curing bodily pains once a week in two years Patient admits to be a hard coffee drinker Patient does not smoke or consume alcohol

General condition
General appearance
Moderately ill

conciousness
Compos mentis

Height
168 cm

Weight
70 kg

BMI 24,8

VITAL SIGN
BP: 120/80mmHg

Temp: 36,2 C

Vital sign
HR: 76times/minute

RR 20 times/minute

PHYSICAL EXAMINATION
Head

Normocephaly

Conjunctiva anemic +/+ Eyes Sclera icteric -/ Normotia Secret -/Ears Serumen -/ Septum deviation Nose Secret -/ Concha normal
Mouth Oral mucous is anemic

THORAX
INSPECTION
Ictus cordis is invisible, spider nevi (-) PALPATION
Ictus cordis is palpable at 5th ICS LMCS

PERCUTION Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS AUSCULTATION
Regular I - II absence of murmurs and gallop in hearts sound

Thorax
Lung Examination

: Symmetrical Pal : Equal vocal resonance Per : Sonor in both lungs A : Vesicular breath sound in both lung,ronchi (-/-),wheezing (-/-)

Abdominal Examination
Inspection Brown skin, distended abdomen, icteric (-), caput meducae (-) Palpation Pain on palpation at Epigastric Liver not palpable Spleen not palpable Shifting dullness (-) Percussion No pain present on abdominal percussion Dullness CVA (-) Auscultation Bowel sound (+) 2 times/minute. Arterial bruit (-), venous hum (-)

Extremity Examination
Warm acrals
+ +

Oedema

LABoratory findings (05/03/2012)

Test Hb Result 4,3 Normal values (12 17) g%

HT
Leukocyte Trombocyte

14
14.200 700.000

(37 48) %
(5000 10000) /ul (150.000 450.000) /ul

RBG
Ureum Creatinine

135
40 0,6

(80 140) mg/dl

(10 45) mg/dl (0.4 1.5) mg/dl

March 5th 2012 Basophil Eosinophils Band Neutrophils Segmented Neutrophils Lymphocyte Monocyte

Patient result 0 1 2 81 20 3

Normal range 0-1% 1-3% 2-6% 40-70% 20-40% 2-8%

Reticulosyt MCV
MCH MCHC RDW

2,4 90
34 38 16

0,5-1,5% 82-91 cu m
27-34Pg/cell 32-35 hb/cell 11,6-14,0%

Peripheral Blood Smear (sadt)

Eritrocyte : polikromasi, anisopoikilositosis (ovalosit) Leucocyte: increasing, hypersegmentation Trombocyte : increasing, trombosit cluster (+) Impression: anemia normositer normocrom dd: infection

RESUME
Symptoms
,51 years old, black and bloody excreta since two days before hospital admittance Fatigue since two days before hospital admittance epigastric pain Nausea Vomiting Lost of appetite Headache consume traditional herbal medicine for curing bodily paiins once a week and analgetic drug for his headache in two years history of gastritis (+) patients often consumed spicy and sour-flavored food.
Signs Laboratory and others

Eyes : Conjungtiva anemic Mouth : Oral mucous anemies Abdomen: Inspection: distended (+) Palpation: - Pain on palpation at Epigastric

Hb: 4.3 g%
leukocyte: 14.200/ul Ht:14% Trombocyte:700.000/ul Segment : 81 % Reticulocyte : 2,4cu m MCHC : 38 hb/cell RDW : 16 %
Peripheral blood smear (SADT) Impression: anemia normositer normokrom. Dd: infection

Differential diagnosis
Anemia gravis e.c. melena ec gastritis erosive Anemia iron deficiency Anemia gravis e.c duodenitis erosive Anemia gravis ec esophageal varices Anemia gravis e.c peptic ulcer

WORKING DIAGNOSIS

Anemia Gravis e.c. Melena e.c. gastritis erosive

Recommended examinations
Endoscopy Serum Iron Total Iron Binding Capacity (TIBC) Erythrocyte sedimentation rate (LED) Urinalysis (protein,glucose) Liver function (SGOT, SGPT, bilirubin ) Blood test (H.pylori) Electrolyte level

Treatments
IVFD NaCl 0.9 % 20 tpm Kalnex 3 x 1 amp Omeprazole 1 x 1 amp Ceftriaxone 1 x 2 gr Ranitidin 2 x 1 amp PRC transfusion (6 packs)

prognosis
Ad Vitam Dubia ad Bonam
Ad Fungsionam

dubia ad
Bonam

Ad sanationam dubia ad malam