Hematemesis Melena e.c.

Gastritis Erosif
with AKI and Hypertension grade.II
Annisa Juwita
030.07.027

Name

Address

Marital status

Education

Identity

Anamnesis
Main complaint

History of present illness

Patient came to emergency room RSUD Karawang with
complaint vomiting of blood, color is black like coffee 3
times since 1 day before hospitalized. The amount of
vomit is 250 cc, consist of blood together with water
and food.
Patient complaint about black and tarry stools 3 times
since 1 day before hospitalized, thick consistency, no
pain.
He admitted he often consumed jamu putri sakti and
AINS from drug stall to cure rheumatic for the last 2
months. Consuming alcohol denied.

History of present illness

He also complaint about epigastrium pain,
nausea, malaise, and shortness of breath when
doing activities, and feel more comfortable
sleeping with 2 pillows.
Mixi is normal, no blood.
Dizziness, cold, cough, chest pain are denied.

History of past illness

Patient
Hypertension
DM
Food
Asthma
(-)
and
never
(-)drugs
had
(+)
allergy
since
same(-)
25
symptom
years ago
before

Family history
Same
Hypertension
Asthma
Food
DM
(-)
and
illness
(+)
drugs
before
(+)
allergy (-)

Medication history

General condition
General appearance

Physical examination
Head

Thorax examination

- Lung examination
Inspection : Symmetrical
Palpation : Equal vocal fremitus
Percussion

: Sonor

Auscultation : Vesicular breath sound in

both lung, no ronchi and wheezing

- Heart examination
Inspection : Ictus cordis is available
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

Abdominal examination
Inspection

Extremity examination
Warm acrals

Oedem

Laboratory examination
February 1st 2012 Patient result

Normal range

Hb

9,2 g%

12 17 g%

Leukocyte

8700/uL

5000-10.000/uL

Trombocyte

201.000

150.000-450.000

Ht

30 %

37-48 %

Differential counting :
-Basofil
-Eosinofil
-Batang
-Segmen
-Limfosit
-Monosit

0%
0%
0%
83 %
15 %
2%

GDS/reduction

74 mg/dl

80-140 mg/dl

Ureum

124 mg/dl

10-45 mg/dl

Creatinin

2,39 mg/dl

0.4-1.5 mg/dl

(0-1)%
(1-3)%
(2-6)%
(40-7)%
(20-40)%
(2-8)%

GFR:
= (140- age) x weight x 0,85
72 x plasma creatinin
= (140-61) x 70 x 0,85
72 x 2, 39
= 27,3 mL/mnt/1,73m

X - ray
CTR > 50%
Cardiomegaly

Resume
Symptoms

Signs

Laboratory and other

Vomiting of blood ,
color black 3 times/day
since 1 day before
admitted to hospital.
Black and tarry stools 3
times/day
Abdominal pain
Nausea
Malaise
Shortness of breath
Consumed jamu and
AINS for the last 2
months
History of hypertension

Vital sign :
BP : 180/100 mmHg
HR : 70 x/ minute
RR : 20 x/ minute
Temp : 36,6 C

Hb : 9,2 g%
Ht : 30%

Anemic conjunctiva +/
+
Palpation: pain in
epigastrium regio

Ureum : 124 mg/dl

Creatinin : 2,39 mg/dl

Differential diagnosis
Hemetemesis melena et causa Hypertension
Portal
Hematemesis melena et causa Hepatitis B
Hematemesis melena et causa Varises
Esophagus
Hematemesis melena et causa Cirrhosis hepatis

Working Diagnosis
Hematemesis melena et causa Gastritis Erosif
Acute Kidney Injury
Hypertension grade II

Suggested examination
HBeAg, anti Hbe, anti HCV
Electrocardiography
Urinalisa
Ultrasonography hepar
Phisiology hepar ( albumin, globulin, GGT)
Electrolit

Treatment

Bed rest
NaCl
30 dpm i.v
Ranitidin 2x1
Ondancentron3x1
Pantoprazol 1x1 fl
Kalnex
3x1
Impepsa syrup 4xC1
Captopril 3x12,5mg

Prognosis
Ad vitam
: ad bonam
Ad fungsionam : dubia ad bonam
Ad sanationam
: dubia ad bonam

THANK YOU