Gastro Esophageal Reflux Disease (GERD)

Guiding lecturer : Dr. Irwin Sp.PD By: Noor Ain bt Mohd Hariri

Name: Mrs. E

Age: 40 years old

Address: Desa Cengkong,Kec Purwasan Occupation:Housewife

Religion: Islam
Ethnic: Sunda

Marital Status: Married

Date of admission: October 6th 2012

Clinical history
Chief complaint
Burning-pain especially on upper stomach

Additional complaint

Heartburn Nausea Regurgitation Loss of appetites Headache Muscle weakness

Mrs E come to the emergency unit,Hospital Karawang on Saturday night,6th October 2012 because of burning pain in her stomach.Besides,shes feeling weak and fatigue. She started feeling weak 2 days before,without any cause.From that point,she started to loss her appetite.On Thursday she drank coconut water,ate mungbean soup and ate a lot of green,unripe mangoes.

On Friday however,her stomach started feeling burning-pain,especially on upper stomach.She had diarrhea twice.She felt extremely weak after that, and her head hurts especially on the forehead.She also feeling nausea and vomiting water.On that instance she felt heartburn and feeling regurgitation in her throat and behind her nose. The burning sensation only presence after she ate and last a few minutes.Afraid that she might throw up,she ate only 2 spoons of porridge on Friday and ate nothing on Saturday.

After admitted in the ward, she never diarrhea, vomiting,and only have mild burning pain and headache. Overall,her condition becomes better and she regain her appetite.

Same illness (+) Allergy (-)

Hipertension (-) Asthma (-)

Diabetes Mellitus (-)

GI Disease (-)

Same symptom (-) Allergy (-)

Hypertension (unknown) GI disease (-)

Diabetes Mellitus (unknown) Asthma (-)

Always eating fruits & vegie

Seldom excercise

Never consume drugs

Always consume herbal supplement

Never drink & not a smoker

Loves eating sour food

She does not taking any drugs to relieve her pain.Going to the hospital is her first attempt to cure her illness.

General appearance : Mildly ill Conciousness : Compos mentis

BP : 110/80mmHg Temperature: 36,2C

Vital sign

RR: 16x/m

Pulse: 80x/m

Head
Eyes Ears Nose

Normocephali Pupil isokor, CA -/-, SI -/ Normotia, secrete-/-, serumen-/septum deviation (-), secrete -/-, concha normal, mucosa not hyperemic dry mouth (-), normal papil,mucosa hyperemic (-), teeth caries (-)

Mouth
Throat Neck

Tonsils T1/T1 pharynx hyperemic (-)

Lymph nodules not palpable, tiroid gland not palpable, JVP 5+2 cm H20

Lung

Inspection : Symmetrical Palpation : Equal vocal fremitus Percussion : Sonor Auscultation : Vesicular breath sound in both lung, no ronchi and wheezing

Heart

Inspection : Ictus cordis is invisible Palpation : Ictus cordis is palpable at 5th ICS LMCS Percussion : No enlargement of the heart Auscultation: Regular I - II heart sound no murmur and gallop

Inspection Palpation

caput medusa(-), smiling umbilicus (-)

Pain present on palpation at all abdominal region, esp. Epigastric No pain present on abdominal percussion Sounds tympany

Percussion
Auscultation

Bowel sound (+)

Warm acrals

+
-

+
-

Edema

August 6th 2012

Hb Leukocyte Trombocyte Ht GDS

Patient result
10,5 g% 6,400/uL 171.000 32 % 71 mg/dl

Normal range
12 17 g% 5000-10.000/uL 150.000-450.000 37-48 % 80-140 mg/dl

Ureum
Creatinine

21,9 mg/dl
0,82 mg/dl

10-45 mg/dl
0.4-1.5 mg/dl

August 7th 2012 GDS

Patient result 108 mg/dl

Normal range 80-140 mg/dl

August 8th 2012

Patient result

Normal range

GDS

124 mg/dl

80-140 mg/dl

August 9th 2012

Patient result

Normal range

GDS

133 mg/dl

80-140 mg/dl

Symptoms

Signs

Laboratory and others

Hb 10,5 g% Ht 32 % GDS 71 mg/dl

Burning-pain especially on upper Pain present on stomach palpation at all abdomen Heartburn region especially Nausea Epigastric Regurgitation Loss of appetites Headache Muscle weakness

Achalasia Stenosis esophagus Gastritis Tumour esophagus Duodenum ulcer Peptic ulcer

Esofagography with barium

Endoscopy

Ambulatory acid (pH) probe tests

Dextrose 5% 20d/m Omeprazole 2x1 Mucoguard 3x1 Cth Fucoidan 1x1

Medications

Non-medications

Avoid sour,spicy,fatty foods Eat meals in small portions Dont lie down after eating Elevate bed

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