HEMATEMESIS MELENA

Pasien 70 tahun perempuan wanita BAB hitam (lengket dan kalau disiram jadi darah) dan muntah hitam
ANAM
 Muntah hitam sejak kapan, jumlahnya (gelas aqua), warnanya, ada gumpalan atau gak, isinya
bercampur makanan atau gak? Berbusa gak - hemoptisis? Disertai batuk?
 Gangguan menelan, mual, nyeri perut, kembung – begah, gangguan tidur
 Lemas, penurunan kesadaran, jantung berdebar, keringat dingin
 Keluhan BAK  makin pekat, jadi lebih sedikit, terakhir kapan?
 BAB hitam  konsistensi, volume, disertai dengan darah segar, kalau disiram ada darah atau gak?
Lengket gitu” gak?
 Demam, penurunan berat badan, riwayat kuning, riwayat infeksi hati  pemakai jarum suntik
 Riwayat konsumsi obat anti nyeri  kenapa?, obat warung, jamu, pengencer darah jangka panjang
 Riwayat merokok, pecandu alkohol, transfusi,
 Riwayat penyakit dahulu  jantung, stroke, DM, OA, CKD, HT
 Riwayat pengobatan
 Riwayat penyakit keluarga

PF
Kalau gawat  tanganin dulu aja baru stabil
Kalau ongoing bleeding atau diare kronik  tanganin dulu
A, B, C  cek urin (kateter)
Mata: CA, SI
THT: Darah ada gak, frenulum lunulae
Thorax: gynecomastia (sirrhosis), spider naevi
Paru dan jantung: auskultasi aja
Abdomen: Inspeksi: caput medusa. Perkusi: shifting dullness, ruang traube. Palpasi: schufnner, hepatomegaly
Ekstremitas: palmar eritema, akral dingin, teri nails, leukonikia
RT  BAB hitam
Asterixi cyst  encephalopathy hepaticum

Pemeriksaan penunjang:
 Hb (<10), Ht, WBC (5000-10000) diif count, trombosit (150-400), ESR, SGOT (40), SGPT (41), Ureum
(<50), creatinine (0.5-1.3), elektrolit (Na 137-145, K 3.5-5, Cl 98-107), GDS (<200), PT, aPTT
 HbsAg, Anti-HCV
 USG abdomen

Diagnosis: Hypovolomic shock ec PVO ec Sirrosis hepatis child pugh C ec Hepatitis C kronik

Tatalaksana:
 Stabilisasi hemodinamik
 NGT alirkan
 Puasakan sampai NGT jernih, >24 jam baru kasih dextrose 10% 500ml/8 jam
 Tranfusi kalau Hb< 8  targetnya 8  deltaHb x KgBB x 4
 Somatostatin  250 ug bolus  250uc/jam selama 72 jam atau sampai dikonsulkan
 Konsul Sp.PD, KGEH  endoskopi ligase sito
 Antibiotik  ceftriaxone 1x2 gr IV
 Lactulose 3x1 cth
 Omeprazole IV 1x40 mg
 Pas mau pulang kasih propranolol 2x10 mg
ACS and AHF denovo DD ADHF
ADHF  pencetusnya CHAMP (coronary, HT emergency, arythmia, mechanical - murmur, Pulmo emboli)
ANAM:
 Sesak  DOE, PND, orthopnea, sejak kapan, paling
parah kapan, ada posisi yang enakan gak
 Sakit saat bernafas, bunyi nafas mengi,
 Batuk? Dahak? Warna, jumlah, darah?
 Nyeri dada? Typical or atypical? Sejak kapan?
 Kanan: leher kerendem, kaki kerendem, congesti hepar
 Sebelumnya sering sesak gak? Pernah control ke
jantung gak? Riwayat bengkak di kaki? Minum obat
yang bikin kencing?
 DD: trauma kepala, penurunan kesadaran, THT
trauma, benjolan di leher, massa di mediastinum, singkirin infeksi pneumonia, efusi pleura, GERD
 RPD: riwayat asma, DM, HT, Jantung
 RPO

PF:
 KU, GCS
 TTV, SpO2
 HR itung harus pegang dua”nya tangan
 Auskultasi jangan lupa pegang nadi juga
 Ca, SI, cyanosis central, JVP, jantung membesar (batas jantung) S3 gallop, pulmo (rhonki basah halus),
Hepar – hepatojugular reflex, Limpa
 Ekstremitas: crt, edema, hangat/dingin, a. dorsalis pedis

PP:
 EKG, Xray thorax, AGD
 BNP  beneran jantung atau dari yang lain, sensitive (rule out) but not specific
 Enzim jantung, Hb, Ht, WBC, diif count, trombosit, SGOT, SGPT, Ureum, Creatinin, elektrolit, GDS
 Curiga emboli: d dimer  clear lung, sesak, saturasi terus menerus

Tatalaksana:
 Kalau ada cardiogenic failure or respiratory failure  tanganin dulu
 Voler position (bed naikin 45 derajat)
 A, B, C  PASANG MONITOR, Oksigen
 LOADING ACS
o Anti angina:
 ISDN sublingual 5mg boleh diulang setiap 5 menit sampai 3 kali go tooo
 NTG IV 10-20 mcg/min maximal 200 mcg
 Morphine IV 2-4 mg dapat diulang tiap 10- 30menit
 Kontraindikasi: Right MI (inferior 2,3, avf), hipotensi, bradikardia, post pemakaian viagra
o Antiplatelet
 Aspirin  Loading dose 160mg  maintanance 80mg/hari PO
 Clopidogrel  Loading dose 300mg (mau fibrinolitik)  maintanance 75mg/hari PO 
Loading dose 600mg (mau PCI)
 Kalau gak clopidogrel bisa ticagerol loading 180 mg
o Anticoagulant
 Enoxaparin 2 x 0.6 ml SC (60mg)
 UFH  IV bolus of 50-70 units/kg  Max 5000IU
o Reperfusi – PCI /revaskularisasi – Fibrinolitik
  STEMI  < 30 menit: door to needle (fibrinolitik) < 90 menit: door to baloon (PCI)
 NSTE-ACS - Kapan mesti PCI

 PCI

 Fibrinolitikassess dulu kontraindikasi absolut dan relatif fibrinolitik

o Lain-lain
 HipertensiACEI/ARB + BB/CCBTarget: <140/90 mmHgEdukasi: Restriksi garam (<
2gram/hari)
  Dislipidemia
Diberikan bila LDL > 100mg/dL Target: <70mg/dL

 Edukasi: Pencegahan kejadian berulang: Turunin BB sampe IMT 18.5 – 24.9 kg/m2
(ideal), olahraga, berhenti rokok, target TD < 140/90mmHg, target kolestrol < 70 mg/dL,
DM terkontrol.

 Tentukan dia masuk kelas HF yang mana

 Pasang kateter  pantau urine output
 Warm and wet  give diuretics Furosemide IV 40mg – 60mg bolus – drip sesuaikan UO and
vasodilator NTG IV 10-20 ug/min
 Cold and dry  fluid challenge  kasih 200cc bolus cepat - TTV meningkat apa enggak kalau enggak
berarti dia cardiogenic shock  kalau membaik resus cairan – DR VITO
 Cold and wet  kalau normal BP kasih vasodilators and diuretics, kalau BP turun kasih ionotropic dan
diuretics
o Dobutamin 2-30 ug/kgBB/min
o Dopamin 3-5 ug/kgBB/min
o Norepinephrine 0.2-1 ug/kgBB/min
 Kriteria perbaikan  RR berkurang, Rhonki berkurang, takikardia berkurang, S3 bisa ilang bias enggak,
urine output keluar
JAUNDICE
ANAM:
 Kuningsejak kapan, tiba-tiba/perlahan-lahan, demam, mual muntah, nyeri perut. BAB dan BAK? BAK
kayak teh? BAB pucat? BAB dempul, gatal (bilirubin tinggi). Demam dulu/kuning dulu?
 Prehepatik: kuning perlahan-lahan, riw. Transfuse, tnd” anemia (lemas, pusing, sesak, debar-
debar).
 Intrahepatik: kuning perlahan-lahan.
Hepatitis: demam, mual muntah, nyeri perut
Sirosis: less likely, bengkak tubuh. Ascites (perut membesar ga, baju sempit, celana sempit, cincin
sempit, sandal muat ga)
Malignancy: Turun BB, perdarahan, alkohol, DM, HT.
Post hepatik: BAB dempul
Billiary: demam, nyeri perut kolik, batu?
 RPD
 RPK
 Obat
 Merokok/alkohol
 Mens, pil KB

PF
 KU, Kes
 TTV
 Gen exam
 Mata: KA, SI
 Hidung: epistaksis
 Mulut: gum bleeding, frenulum lidah, pucat, central cyanosis.
 Leher: benjolan lymphadenopathy)
 Thorax
 C/P/: IPPA
 Abdomen (LIPAT KAKI!)
 I: bentuk (cembung/datar), caput medusa, venektasi, Cullen greyturner sign
 A: BU, aortic&renal bruit
 P: Timpani seluruh lap abdomen, shifting dullness + poodle sign + fluid wave, ruang traube, ketok CVA
 P: light and deep palpation, cari batas atas paru hati, palpasi liver tip (hitung liver span), schuffner,
ballottement, murphy sign
 Tnd” app: mcburney, rovsing, dunphy, obturator, psoas sign.
 Suruh duduk cek belakang CVA
 Ekstremitas: akral hangat, CRT<2 detik, nadi kuat angkat regular penuh, clubbing finger
 Sirosis: asteriksis, leukonikia, koilonikia
 Edema?

PP
 Lab: FBC, Ur Cr GFR, SGOT SGPT, albumin, globulin, GGT, ALP, AFP (hepatoma), CA 19-9 (pancreas),
CEA (colon), amylase lipase (lbh sensitif), fungsi hati (fungsi koagulasi).
 UL & FL
 Serologi hepatitis (igm anti HAV, hbsag, anti hbs, hbv dna, hcv rna)
  USG whole abdomen.
 Susp autoimmune hep: ANA, anti dsdna
 Susp batu: CT abdomen kontras, ERCP, MRCP

Terapi
1. Hepatitis A
Suportif: Boleh pulang. Kompres aja, jgn PCT. Domperidone 3x10 mg. OMZ 2x20 mg, Curcuma 3x200 mg,
CTM 3x10 mg.
Edukasi: tidak berbahaya, dapat pulang, makan bersih. Bisa menyebar via makanan, sementara jgn makan
minum dr 1 wadah yang sama.
Cuci tangan sblm makan.
Asupan kalori dan cairan adekuat, ist total di tempat tidur (10 hari dari kuning br boleh aktivitas).
Dapat sembuh sendiri, bisa vaksin hep A.
Indikasi rawat: gejala klinis berat, muntah hebat, intake ga bagus, dehidrasi butuh IV, hepatitis fulminant
(kuning parah).
Prognosis: 10-15 kasus dpt relaps dlm 6 bulan.
Gagal hati akut (gg. Status mental, perdarahan 8 minggusetelah onset akut)

2. Hepatitis B (Tny jg ortu Hep B garisk sirosis lbh tinggi)

Konsultasi Sp.PD, rawat inap?
Hbsag dan hbv dna setiap 3-6 bulan.
Preikterik 1-2 minggu.
Ikterik prodromal hilang, lalu kuning.
Konvalesen.
Tatalaksana: suportif (tirah baring, asupan nutrisi
IgM anti HBC +.
Bila fulminant: Lamivudine 100 mg/hari selama 6 bulan.

3. Leptospirosis
Demam mendadak, menggigil, nyeri kepala frontal, nyeri otot (betis), hiperestesia kulit,
mual ,muntah ,diare, penurunan kes. Tny pekerjaan (petani), banjir, rawa.
Photophobia, mata merah.
Wells: ikterik, perdarahan, gg. Ginjal, bs kena paru jg. (4-9 hari)
PFdemam, relative bradikadi, hepatomegali, RUQ pain, pericarditis, petekie, epistaksis, NT
gastrocnemius.
Penunjang: dark field mikroskop (dr cairan tubuh), LED, kultur, serologi (Microscopic agglutin testMAT)
Terapi:
Suportif
Ringan: Doksisiklin oral 2x100 mg selama 7 hari
Berat: Penisilin G IV 1,5 juta unit/6 jam selama 7 hari.
Edukasi: bed rest.

PR: kole-kolean.

Desensitisasi mulai kaalu udah gak mual dan sgot/sgpt udah bagus rifampicin 75mg
Mulai INH 25 mg, per 3 hari naikin 2x lipat – cek liver per 3 hari dan pantau gejalanya – gejala – lini 2
PEP
1. Pathof PND, S3, Clubbing fingers
Paroxysmal nocturnal dyspnea or paroxysmal
nocturnal dyspnea (PND) refers to attacks of
severe shortness of breath and coughing that
generally occur at night. It usually awakens the
person from sleep, and may be quite
frightening. Though simple orthopnea may be
relieved by sitting upright at the side of the bed
with legs dangling, in those with PND, coughing
and wheezing often persist in this position.
PND is caused in part by the depression of the
respiratory center during sleep  which may
reduce arterial oxygen tension, particularly in
patients with interstitial lung disease and
reduced pulmonary compliance.
Similar to orthopnea, in the horizontal position
there is redistribution of blood volume from
the lower extremities to the lungs. In normal
individuals this has little effect on lungs, but in
patients in whom the additional volume cannot
be pumped out by the left ventricle due to left
ventricular weakness, there is a significant
reduction in lung capacity which results in
shortness of breath. Additionally, in patients
with congestive heart failure the pulmonary
circulation may already be overloaded because
of the failing left ventricle. When a person lies down, the left ventricle is unable to match the output of a
more normally functioning right ventricle on increased venous return to the lungs; causing pulmonary
congestion. Pulmonary congestion decreases when the patient assumes a more erect position, and this is
accompanied by an improvement in symptoms.
RECUMBENCY  VENOUS RETURN  PRELOAD  PULMONARY VENOUS PRESSURE  DYSPNEA

S3  it is produced during rapid filling of cardiac cycle

Produced due to vibrations which set up in ventricular wall, due to rushing of blood in to ventricles during
rapid filling phase
Oscillation of blood back and forth between the wall of ventricles

CLUBBING FINGERS