MORNING REPORT

C3
A 59 year-old female was admitted to R.D.
Kandou Hospital at C3 ward on Monday, April
10th, 2017 at 17.20 wita

With main complaint: Vomitting

 Patient’s identity
Name : Mrs JR
Age : 59 yrs
Sex : Female
Occupation : Housewife
Education : Junior High School
Ethnicity : Minahasa
Religion : Christian
 Present Medical History

• Vommiting since 1 day b.a. 5 times, contain food and

fluids, volume 50cc. After consume spicy food.
• There were tumors at right breast since 1 year ago.
Patient didnt get further examine, pain(-), bloody (+).
• Fever (-), cough (-)
• Defecating and urinating had no complain.
 Past Medical History

• History of previous hypertension, DM, heart, lung,

liver, kidney was denied.
History of allergy :
Unknown
History of immunization :
Unknown

Habit history :
Alkoholism (-), Smoking (-)
 Family History
• None experienced the same illness
General anamnesis ( review of system )
General :-
Skin :-
Head and neck : -
Eye :-
Ear :-
Nose :-
Mouth and throat: -
Respiratory : -
Chest : Tumors on right breast
Heart :-
Abdomen : Vomitting
Genitalia :-
Kidney :-
Hematology :-
Endocrine :-
Musculosceletal : -
 Physical Examination
• GC: Moderate ill Sens : CM
• C3:BP: 120/80mmHg, PR 96x/m, RR 20x/m, T 36,5ºC SaO2 98%
• ER :BP: 120/80mmHg , N 88x/m, RR 18x/m, T 36,3 C SaO2 98%
• BW 58 kg, BH 158 cm, BMI 23.3 kg/m2
• Head : conj. anemic (+), scl. icteric(-),
• Neck : JVP 5+0 cmH20, lymph nodes enlargement (+) right axilla
• Thorax (breast):
– Right : tumors +.7x5cm Ireguler, hard, no mobile, pain(-), peau d orange (-)
• Heart :
– Insp : IC not visible
– Palp : IC not palpable,
– Perc : left border: ICS V 1cm lateral midclavicullar line
right border: ICS IV sternal line
– Ausc : SI-II regular, murmur (-), gallop (-)
 Physical examination
• Lung : Insp : Symmetric
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular, ronchi -/-, wheezing -/-
• Abd :
Insp : Flat
Palp : Tender, epigastric pain (+),
Liver and spleen not enlarged
Perc : Tympanic in all regions, shifting dullness (-)
Ausc : Bowel sound (+) normal
• Waist : Pain on CVA exam (-/-)
• Extr : warm, edema (-/-), washer women hands (-)
ECG : Sinus rhythm, 90x/min
 ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus Sinus Rhythm
Speed / HR (times/mnt) 94x/min 1500/R-R’
Axis Normal Normal / RAD / LAD
Morphology P wave 0,10 sec Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0,20 sec 0,12” – 0,20”
QRS complex duration 0,08 sec 0,05” – 0,11”``
ST segmen Normal Normal / Elevated / Depressed
T wave Normal Normal / abnormal
QT Interval 0,40 sec cQT = QT interval / vR-R’ Interval
U wave Absent Appear / not appear
CONCLUSION : Sinus rhythm, HR 90x/m
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring

1 Na,K,Cl control o
IVFD Ns0,9%→ •Educate the •Observation for
•Vomitting 20gtt/m family about the vital signs.
•Pain at the •Ranitidin 2x1 iv condition of the
epigastrium •Ondancentron 3 patient and plans •Observation for
x 1 iv ahead. abdominal pain.
•Sucralfate 4 x cth
II po •Educate not to
GC: Moderately ill. take spicy food
Sens : CM
Abdomen: •Educate about a
epigastric pain on diet
palpation +.

→ Dyspepsia
syndrome
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring
2. Conj. Anemic (+) •Blood smear
o
PRC transfusion 1
bag/d till Hb>=10
•Educate the
family about the
•Observation for
vital signs.
Hb: 5.1 •CBC gr/dl condition of the
patient and plans
MCH 27 •Reticulocyte ahead.
MCHC 35
MCV 80

 Anemia ec
malignancy

3. • Tumors right •Lab : DL, Consult •Educate the Observation for vital
breast since 1 • Diff count haematology family about the signs.
year Ca153 division condition of the
•FNAB patient and plans
PF : •USG abdoment ahead.
•CT Scan
Right : Tumor 7x5 cm, Thoraks pro
hard, immobile, staging
ireguler, pain (+),
bloody (+)

 Ca Mammae
dextra
No Problem List Plan Dx Plan Tx Plan Plan Monitoring
Education
4 Na : 132 Na urine IVFD NaCl 0.9% 20 Educate the • Vital sign
gtt family about • Na serum
Na needed : 0.6 x the condition
58 x 10 = 348 meq of the patient
and plans
ahead.

 Hyponatremia
 Lab Result
9/4/2017
• Leucocyte 7300
• RBC 2.13
• Hb 5.1
• Ht 15.7
• Platelet 302,000
• MCH 27
• MCHC 35
• MCV 80
• RBS 129
• Ureum 21
• Creatinin 0.7
• Natrium 132
• Kalium 3.3
• Chloride 107
 Problem List
No CM : 45.20.99 Age : 59 y.o
1. Main complain:
Vomitting
2. Anamnesis:
Epigastric pain
Tumors on right breast
3. Physical examination:
• GC: Moderate ill Sens : CM
C3:BP: 120/80mmHg, PR 88x/m, RR 20x/m
• Thorax (breast):
– Right : tumors +.7x5 cm. Ireguler, hard, no mobile, pain(-), peau d orange (+), bloody
(+)
 Prognosis
• Ad Vitam : Dubia
• Ad Functionam : Dubia
• Ad Sanationam : Dubia
 Conclusion
• Has been reported A 59 year-old woman
admitted to R.D. Kandou Hospital at C3 ward
on April 10th, 2017 at 17.20 with main
complain vomitting, from anamnesis, physical
examination an laboratory diagnosed with
Dyspepsia syndrome. Ca Mammae dextra.
Anemia ec malignancy. Hyponatremia.
Thank You
 Definisi
• Dispepsia adalah kumpulan gejala nyeri
atau rasa tidak enak di abdomen atas
yang episodik atau persisten, kronik atau
rekuren yang disebabkan oleh berbagai
faktor
• Dikenal juga sebagai overlap syndromes
(sindroma tumpang tindih)
 Etiologi
• Disebabkan oleh berbagai faktor
• Sekitar 50 – 60 % Pasien termasuk
kategori dispepsia fungsional
• Sekitar 40 % disebabkan oleh gangguan
struktur / organ
Tabel 1. Diagnosis Banding Penyebab Dispepsia
Kategori diagnostik Prevalensi
Dispepsia fungsional Sampai 60 %
Dispepsia karena penyakit struktural atau biokimia
Tukak peptik 15 – 25 %
Esofagitis refluks 5 – 15 %
Kanker lambung atau esofagus <2%
Penyakit saluran bilier Jarang
Gastroparesis Jarang
Pankreatitis Jarang
Malabsorbsi karbohidrate (laktose, sorbitol, fruktose, mannitol) Jarang
Obat – obatan Jarang
Penyakit infiltratif lambung (Penyakit Crohn, sarcoidosis) Jarang
Gangguan metabolik (hiperkalsemia, hiperkalemia) Jarang
Hepatoma Jarang
Penyakit usus iskemik Jarang
Penyakit sistemik (diabetes melitus, penyakit tiroid, and Jarang
paratiroid, penyakit jaringan ikat)
Parasit usus (Giardia, Strongyloides) Jarang
Kanker abdomen, terutama kanker pankreas Jarang
 Patogenesis
• Ketidak seimbangan antara faktor agresif
dan faktor defensif
• Bila faktor agresif lebih kuat atau faktor
defensif lebih lemah maka akan terjadi
kerusakan mukosa gaster
 DISPEPSIA

Investigasi

Kelainan organik – biokimiawi

+ -

Penyakit organik Dispepsia fungsional

(gastritis, dll)
 Penatalaksanaan
1. Non Farmakologi
• Perbaiki keadaan umum
• Perbaiki cairan dan elektrolit
• Diet bahan yang tidak iritatif pada lambung
• Psikoterapi
2. Farmakologi
Penanganan Farmakologi dispepsia :
1. Antasida
2. Penghambat sekresi asam
a. Anti – muskarinik
b. Antagonis H2 – reseptor (simetidine, ranitidine dan famotidine)
c. Penghambat pompa proton (PPI) = omeprazole, lansoprazole,
pantosazole, rabeprazole dan esomeprazole

3. Sitoproteksi
a. Sucralfate d. Prostaglandin
b. Cetraxate e. Teprenone
c. Colloidal Bismuth subcitrate
4. Anti Free radical – Anti Inflamasi
a. Rebamipide
5. Eradikasi kuman H. pylori
 DISPEPSIA

Usia < 45 th Usia > 45 th atau < 45 th

tanpa bahaya dengan tanda bahaya
Riwayat pemakaian OAINS kronik
Riwayat kanker pada keluarga
Terapi
Terapi empirik Dispepsia (-)
dihentikan
2 mg

Tanda bahaya ;
Dispepsia (+)
Muntah hebat
Demam
Hematemesis
Serologi (tervadilasi lokal)
Anemia
Ikterus
Berat badan menurun
Hasil (+) Hasil (-)

Endoskopi

Sarana Endoskopi (-)

UBT / HpSA

Hasil (+) Hasil (+) Terapi eradikasi RUJUK

Internis, internis plus, gastroenterologis

Gagal
atau dokter anak dengan fasilitas
Endoskopi
Anemia
Anemia
Anemia berdasarkan morfologi
Anemia
Anemia normositik normokrom
 Algoritme Diagnosis Anemia Makrositik
Anemia
MCV > 100fl & MCHC > 30g/dl

Indeks retikulosit < 10% Indeks retikulosit 10-15% Indeks retikulosit > 15%

Kadar B12 & Folat Perdarahan/Hemolisis

Definisi Folat Defisiensi B 12 Normal TIDAK YA

Analisa gizi Schilling test BMP

Baik Kurang Terkoreksi Tidak Megaloblastik Non Megaloblastik

Terkoreksi
Def. Intrinsik Hipoplastik
Malabsorpsi
Malabsorpsi Mieloplastik
Inapropriate diet
Cincin sideroblastik Kongenita/Obat
 Algoritme Diagnosis Anemia Mikrositik Hipokrom

Anemia
MCV < 80fl & MCHC < 30g/dl

Indeks retikulosit < 10% Indeks retikulosit 10-15% Indeks retikulosit > 15%

SI / IBC, Transferin, Feritin Elektroforesis hemoglobin

Normal/Tinggi Definisi Fe Normal Abnormal

BMP Pasokan, Absorpsi ? Dalam terapi Fe ? Hemoglobinopati

Gangguan metabolisme Fe Hemolitik ? Thalasemia

Mielodisplasia
ACD
Algoritme Diagnosis Anemia Normositik Normokrom
Anemia
MCV 80-100fl & MCHC > 30g/dl

Indeks retikulosit < 10% Indeks retikulosit 10-15% Indeks retikulosit > 15%

Abnormal hambatan Kehilangan/Penghancuran Berlebihan

Produksi/Pematangan BMP
Periksa: Bilirubin Indirek, LDH
Normal Tinggi
Normal
Anemia hemolitik/def. Fe dlm terapi Perdarahan ?
Periksa ACTH Anemia hemotolik
Tidak Ya
Infiltrasi Keganasan Periksa Urin

Hipoplasia SSTL
Tes coombs, C3/C4 Negatif Positif Hb/
Cincin sideroblastik ? Anti DsDNA hemosiderin

Positif Hemolisis Hemolisis

AIHA Primer or Secunder Ekstravaskuler Intravaskuler

Negatif Detect Intra corpuscular

Detect Intra corpuscular Mekanin, Toksin, Infeksi
 Pengobatan Kausal
• Pengobatan kausal terdiri atas :
– Hentikan perdarahan
– Memperbaiki defisiensi dalam makanan
– Mengobati penyakit-penyakit dasar
– Hindari bahan kimia toksik atau obat-obatan
– Memperbaiki kelainan anatomi saluran cerna.