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CASE REPORT

“DYSPEPSIA“

Preceptor : dr. Hj. Ihsanil Husna, Sp.PD

Arranged by : Ayu Devita Ashari


PATIENT’S IDENTITY

• Name : Ms. Ayu


• Age : 20 years old
• Address : Kemayoran
• Religion : Moslem
• Marital Status : Not married
• Date of admission : March 16th 2018
• MR number : 00921843
ANAMNESIS

• Chief complaint:
epigastric pain since 1 week before entering the hospital.

• Another complaint:
nausea, vomit, fever, cough
HISTORY OF PRESENT ILLNESS

Patient came to Cempaka Putih Islamic Hospital with epigastric


pain since a week before admission. The pain decreases at rest, but
reappear when patient doing some activity. The pain feels like being
stabbed and there is a burning sensation in the epigastric area. Patient
said the epigastric pain was felt after consuming spicy foods. Patient also
complained fever since approximately two days before admission. Fever is
felt throughout the day. Since one month, patient coughs but not often.
The patient has felt nausea and vomit but not much. Patient doesn’t have
problem with her appetite and also doesn’t have problem with urinating
and defecating.
HISTORY OF PAST ILLNESS

• Previously patients has experienced the same complaint about


three months ago.
• No history of hypertension
• No history of cardiovascular disease
• No history of asthma
• No history of allergic
• No history of hematologic disease
HISTORY OF FAMILY

• Patient’s father has history of hypertension


• Patient’s father has history of DM
• No history of allergic
• No history of hematologic disease
HISTORY OF ALLERGY

• Patient has no allergy to food, drugs and weather.


HISTORY OF TREATMENT

Patient has already consumed polysilane for her


epigastric pain.
HABITS

• Patient have a smoking habit about 4 to 5 packs


per day. But has begun to be reduced.
• Patient had a habit of drinking alcohol but it has
stopped a few years ago.
• Patient have a habit of consuming spicy foods.
PHYSICAL EXAMINATION

Generalis Status • General condition : Moderate ill


• Conciousness : composmentis

• Blood pressure : 120/80 mmHg


Vital Sign • Heart rate : 100 x/minute
• Respiratory rate : 18 x/minute
• Temperature : 38° C
GENERAL PHYSICAL EXAMINATION
 Head : Normocephal, deformity (-)

 Eyes : Anemic conjungtiva (-/-), icteric sclera (-/-)

 Nose : Epistaksis (-/-), septum deviation(-/-)

 Mouth : The oral mucosa moist

 Neck : Mass (-), lymphadenopathy (-)

 Thoraks :
• Inspection : the movement of the chest symmetrical
• Palpation : same vocal fremitus in dextra and sinistra
• Percussion : Sonor in dextra and sinistra
• Auscultacion : vesicular breath sounds + / +, ronkhi - / -, wheezing - / -
GENERAL PHYSICAL EXAMINATION

 Heart:
Inspection : ictus cordis not seen
Palpation : ictus cordis not palpable
Percussion : Right heart margin: sternalis line sinistra ICS-IV
Left heart margin: midclavicula line sinistra ICS-V
Auscultation : Regular 1st & 2nd heart sounds, murmur (-), gallop (-)

 Abdomen :
Inspection : looked flat
Auscultation : bowel (+) sounds, 7x/minutes
Palpation : pressure epigastric pain (+), ascites (-)
Percussion : timpani, shifting dullness (-)
GENERAL PHYSICAL EXAMINATION

 Extremities:
Superior : Edema (- / -), warm akral(+ / +), RCT <2 seconds (+ / +)
Inferior : Edema (-/ -), warm akral (+ / +), RCT <2 seconds (+ / +)
LABORATORY EXAMINATION
(16 MARCH 2018)

Hematology

Hemoglobin 12.6 g/dL 11,7 - 15,5 g/dL

Leucosite 9.27 x 103/μL 3,60-11,00 x 103/μL


Hematocrite 36 % 35 - 47 %
Trombosite 253 x 103/μL 150 - 440 x 103/μL
Eritrosite 4,48 x 106/μL 3,80 - 5,20 x 106/μL
MCV 81 fL 80 - 100 fL
MCH 28 pg 26 - 34 pg
MCHC 35 g/dL 32 - 36 g/dL
RESUME

• Ms. A, 20 years old, came to Cempaka Putih Islamic


Hospital with epigastric pain since a week before
admission. The pain decreases at rest, but reappear
when patient doing some activity. The pain feels like
being stabbed and there is a burning sensation in
the epigastric area. Patient said the epigastric pain
was felt after consuming spicy foods.
• Patient also complained fever, cough, nausea and
vomit but not much.
• Patient had a history of the same complaint about
three months ago
• Patient had a habit of smoking, drinking alcohol
and consuming spicy foods.
RESUME

Physical examination :
• BP: 120/80 mmHg
• HR: 100 x/minute
• RR: 18 x/minute
• Temp: 38° C

General Physical examination:


Pressure epigastric pain (+)

Laboratory examination:
• Normal
PROBLEM LIST

• Dyspepsia
• Upper Respiratory Tract Infections
ASSESSMENT

1. DYSPEPSIA
S : Epigastic pain, burning sensation in the
epigastric area, nausea, vomit
O : BP: 120/80 mmHg, HR: 100 x/minute, RR: 18
x/minute, Temp : 38° C.
Pressure epigastric pain (+)
A : Dyspepsia
ASSESSMENT

PLANNING
• Planning diagnostic
• Endoscopy
• Planning therapy
• Lifestyle modification (by reducing smoke, alcohol and
spicy foods)
• Domperidon 3x10 mg
• Ranitidine injection 2x25 mg
ASSESSMENT

2. Upper Respiratory Tract Infections


S : Cough, fever
O : BP: 120/80 mmHg, HR: 100 x/minute, RR:
18 x/minute, Temp : 38° C.
A : Upper respiratory tract infections
ASSESSMENT

PLANNING
• Planning diagnostic
• Sputum for Tuberculosis
• Planning therapy
• Paracetamol 3x500 mg
• Acetylcysteine 2x200 mg
FOLLOW UP
Date Subject Objective Assessment Planning

17/3/2018 Epigastric pain, BP: 110/80 Dyspepsia Paracetamol 3x500 mg


nausea, cough
HR: 90x Domperidon 3x10 mg
URTI
Ranitidin inj 2x25 mg
RR: 20x
Acetylcysteine 2x200
Temp: 36,50C
mg
Pressure
Epigastric Pain
(+)

18/3/2018 Epigastric pain, BP: 110/70 Dyspepsia Domperidon 3x10 mg


nausea, cough
HR: 88x Ranitidin inj 2x25 mg
URTI
Paracetamol 3x500 mg
RR: 20x
Acetylcystein 2x200
Temp: 360C
mg
Pressure
epigastric pain
(+)
FOLLOW UP
Date Subject Objective Assessment Planning

19/3/2018 Epigastric pain BP: 120/80 Dyspepsia Domperidon 3x10 mg


HR: 88x Ranitidin inj 2x25 mg

RR: 20x

Temp: 36,30C

Pressure
Epigastric Pain
(+)

20/3/2018 Epigastric pain BP: 110/70 Dyspepsia Domperidon 3x10 mg


HR: 84x Ranitidin inj 2x25 mg

RR: 19x

Temp: 36,10C
PROGNOSIS

• Quo ad vitam : bonam


• Quo ad functionam : dubia ad bonam
• Quo ad sanationam : dubia ad malam
LITERATURE REVIEW

DYSPEPSIA
DEFINITION

The British Society of Gastroenterology (BSG) states that the


term 'dyspepsia' is not a diagnosis, but rather a collection
of symptoms that lead to upper gastrointestinal diseases /
disorders. The definition of dyspepsia is upper
gastrointestinal tract infections include pain or discomfort
in the gastro-duodenal (epigastric) area, burning, fullness,
full satiation, nausea or vomiting.
CLASSIFICATION

Organic
Dyspepsia
Functional
EPIDEMIOLOGY

It is estimated that about 15-40% of the world's population have


complaints of chronic or recurrent dyspepsia. The highest etiology of
organic dyspepsia is gastric / duodenal peptic ulcer, gastroesophageal
reflux disease, and gastric cancer. However, most of the etiology of
dyspepsia is unknown (functional).
ETIOLOGY

• Idiopathic / functional dyspepsia (50-70%)


• Peptic ulcer (10%)
• Gastroesophageal reflux disease (GERD) (5-20%)
• Gastric cancer (2%)
• Helicobacter pylori infection
• Non-steroidal anti-inflammatory drugs (NSAIDs)

Dietary factors (burnt food, fast food, fatty, spicy, coffee, tea)
and lifestyle (smoking, alcohol, NSAID / aspirin drugs, lack of
exercise) are believed to contribute to dyspepsia. Cigarettes
are thought to decrease the protective effect of gastric
mucosa, while alcohol and anti-inflammatory drugs play a role
in increasing stomach acid production.
RISK FACTORS

• Age >50 years


• Family history of gastric cancer
• History of peptic ulcer
• Failure treatment
• History of gastrointestinal bleeding
• Anemia
• Weight loss
• Persistent vomiting
• High or long term use of NSAIDs
• Alcohol consumption
DIAGNOSTIC

• Distinguishing organic dyspepsia by function


requires an accurate history and physical
examination. Investigations such as blood tests,
endoscopy, and radiology are required in certain
cases. Indication of endoscopy when there are
symptoms or alarm signs.
SYMPTOMS AND ALARM SIGNS

• Age> 55 years
• Gastrointestinal haemorrhage (hematemesis,
melena)
• Anemia
• Dysphagia
• Weight loss (> 10% normal weight)
• Vomiting over and over
• Lymphadenopathy
• Family history of stomach / esophageal cancer
• Palpable abdominal mass
According to Rome III Criteria, the definition of functional
dyspepsia is the presence of symptoms that are thought
to originate in the upper gastrointestinal tract, in the
absence of organic, systemic, or metabolic diseases.
* Diagnostic criteria should include
• One or more of the following:
• a disruptive post-meal feeling
• fast satiety
• epigastric pain
• burning sensation in the epigastric area
• There is no evidence of structural disease (from
endoscopy) that may explain the symptoms.
Epigastric
pain type
Functional
dyspepsia
Postprandial
distress type
PROGNOSIS

• Most patients with chronic and recurrent functional


dyspepsia, with asymptomatic periods followed by
episodes of relapse.
• Based on population study of functional dyspepsia
patients, 15-20% had persistent symptoms, 50% had
symptom improvement, and 30-35% had fluctuating
symptoms. Although functional dyspepsia is chronic
and affects the quality of life, it is not proven to
decrease life expectancy.
CONCLUSION

• Dyspepsia many experienced and disrupt the


quality of life of patients. Classification based on the
presence or absence of organic lesions from
physical and supporting examinations (laboratory,
endoscopy). Consideration of possible non-
gastrointestinal causes should be considered.
Recommended avoidance of risk factors for triggers
and pharmacological therapy.
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Endoscopic appearance
of PHG and GAVE.
(a)The mosaic or ‘snake-
skin’ appearance of
gastric body mucosa
without red spots,
characteristic of mild
PHG.
(b)Congested mosaic
appearing mucosa with
(c) Background ‘snake-skin’ mucosa in the red spots, characteristic
cardia and fundus with red and brown spots with of moderate PHG.
active oozing characteristic of moderate-to-
severe PHG.
(d) GAVE with the classic watermelon stomach
of the antrum, with columns of tortuous ectactic
vessels converging on the pylorus without active
bleeding.