CASE REPORT

ANAMNESIS
Identity : An. IM/F/ 16 y.o
Time of Admission in ER : 4 pm 4/3/20
Chief complain : Abdominal Pain
Additional complain : Melena
Present Illness History
Present
3 Illness History
 Past illness History:

Family History:
• History of dyspepsia in family was his mother.

Immunization history
BCG (+) scar (+)
Hb 0,1,2,3 (+)
DPT 1,2,3 (+), booster (-)
Polio 1,2,3 (+), booster (-)
HiB 1,2,3 (+), booster (-)
Measles (-), booster (-)
Physical Examination

General Condition Weight : 55 kg

General Condition : E4M6V5 Height : 174 cm
Pulse : 92x/m (content and Weight for age: P 0.50 – P 0.75 (normal)
volume enough) Height for age: P >0.95 (normal)
Temp : 36,90C Weight for height: P 0.10 – P 0.25
RR : 29 x/m (good
Spo2 : 98% nutrition)

Spesific Condition
HEENNT : Anemic conjunctiva (+), icteric sclera (-), nasal flaring (-), NCAT
(normocephaly atraumatica), PERLLA (pupil equal round reactive to
light accomodation).
Thorax : Symmetric, retraction (-)
Lungs : Normal vesicular breathe sound, rhales (-), wheezing (-)
Heart : Normal heart sound, murmur (-), gallop (-)
Abdomen : flat, hepar and spleen not palpable, shifting dullness (-),
Abdominal Tenderness on regio hypocondria sinistra
Extremities : warm extremities, CRT <3s, pale palmar skin
Physical Examination

Status neurologikus
Status neurologikus :

6 LKA LKI TKA TKI

Gerakan : luas luas
Kekuatan : +5 +5
Tonus : eutoni eutoni
R. Fisiologis : (+) N (+) N
R. Patologis : (-) (-)
Klonus : (-) (-)
GRM : (-)
PROBLEMS ASSESSMENT
• Abdominal Pain Dyspepsia Syndrome
• Melena

DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS

- GERD Dyspepsia Syndrome

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PLAN EXAMINATION THERAPY
1. IVFD D5 ½ NS
2. Omeprazole 1x20 mg IV
3. Sucralfate Syrup 4x5 ml per oral
4. Vit. K injection 0,3 mg/KgBW before
endoscopy
5. Domperidone 3x10 mg per oral

Examination
6. Laboratory examination
7. Endoscopy
DIET MONITORING
Calories Needed: 1700 kcal • Observe vital signs (especially pain
scale)

Addmission • Gastroenterohepathology

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 Laboratory Finding (4/3/2020)
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Result Normal
Haematology :
Haemoglobin 9,1 11.3-14.1 g/dL
RBC 4,86 4,40-4,48 x 106/mm3
WBC 6,84 4,5 – 13,5 103/mm3
Ht 30 37 – 41%
Plt 308 217 – 497 x 103 /uL
MCV 60.9 81 – 95 fl
MCH 19 25 – 29 pg
MCHC 31 29 – 31 g/dL
D.C 0 / 2 / 61 / 28 / 9 0-1/50-70/20-40/2-8
 Laboratory Finding (4/3/2020)
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Result Normal
Calsium 8,7 9,2-11,0 mg/dL
Blood Sugar 127 <200 mg/dL
Ureum 9 16,6-48,5 mg/dL
Creatinin 0,67 0,57-0,87 mg/dL
Natrium 143 135-155 mEq/L
Kalium 3,8 3,5-5,5 mEq/L
Cloride 109 96-106
 Endoscopy (6/3/2020)
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