Approaches to Univestigated Dyspepsia one of the rule dyspepsia management

1. DUTY REPORT
APRIL 6TH 2016
APPROACHES TO UNINVESTIGATED
DYSPEPSIA
PPDS on duty : dr. Pradipto, dr. Irfan
Coass on duty : Nadhira, Pinta, Eka
Supervisor dr Soroy Lardo SpPD FINASIM
Fakultas Kedokteran Universitas Indonesia
Divisi Penyakit Tropik dan Infeksi Departemen Penyakit Dalam
RSPAD Gatot Soebroto

2. PATIENT RECAPITULATION
1. Mrs. RA 31 y.o.  febris D+5 susp DHF
2. Mr. HA 69 y.o.  loss of consciousness
3. Mr. BA 52 y.o.  abdominal pain
4. Mrs. ER 28 y.o.  febris + urticaria susp viral infection
5. Mrs. RE 27 y.o.  diarrhea
6. Mrs. SU 48 y.o.  dyspepsia

3. PATIENT’S IDENTITY
• Name : S
• Sex : Female
• Age : 48 years old
• Job : Housewife
• Religion : Moslem
• Marital Status : Married
• Address : West Pademangan

4. ANAMNESIS
• Autoanamnesa on 7/4/16 at 2 AM
• Chief Complain :
Nausea since 1 day prior to admission
• Additional Complain : -

5. PRESENT ILLNESS
• The patient complained of having nausea since 1 day prior to
admission. It was also accompanied with epigastric pain since 1 day
prior to admission, with VAS 7/10. There was no worsening or
improvement on the scale of the pain by changing position or eating
meals. She denied of having heartburn or bitter taste in mouth.
• She also vomited more than 5 times, containing food and yellowish
fluid since 1 day prior to admission. There were no history of fever,
cough, blood-contained vomit, and bloody diarrhea.
• There was lost of appetite resulting in decrease intake and
rehydration. There were no urination and defecation problem
reported.
• There was no history of NSAID use.

6. PRESENT ILLNESS
• She complained of having weight loss (+/- 7kgs) since 1 month prior
to admission. She was admitted with the same symptoms 1 month
ago. There was no complaint of pain or difficulty in swallowing, history
of any gastric/duodenal malignancy, intraabdominal mass, or
lymphadenopathy.
• She denied of having hypertension, DM, heart problem, allergy,
asthma.

7. PAST ILLNESS
• There was past history of having the same symptoms and
admitted to Sulianti Saroso Hospital 1 month ago.
• There was no history of any surgery.
• No family member with the same symptom
• HT –
• DM –
• Asthma -
FAMILY ILLNESS

8. SOCIAL, HABIT, AND LIFESTYLE
• She is married and currently has two kids.
• She is a housewife.
• She has no habit of drinking soda, alcohol, tea, coffee, or
sour food. She likes eating spicy meals.
• Smoking (-), alcoholic (-), IVDU (-), promiscuity (-).

9. PHYSICAL EXAMINATION
VITAL SIGNS
• General State : Moderately sick
• Consciousness : Compos Mentis
• Blood Pressure : 130/90 mmHg
• Pulse : 88 x/minute, regular
• Respiratory Rate : 20 x/minute, regular
• Temperature : 36.5oC
• Body Weight : 71 kg
• Body Height : 155 cm
• BMI : 29,5 (Obese grade I)

10. PHYSICAL EXAMINATION
General Examination
• Head : Normocephal
• Eye : anemic conjunctiva (-/-), icteric sclera (-/-)
• Ears : normotia, discharge (-)
• Nose : septum deviation (-), discharge (-)
• Mouth : hyperemic pharynx (-)
• Neck : JVP 5-2 cmH2O lymph nodes enlargement (-)

11. • Thorax: symmetric, intercostal retraction (-)
• Cor : regular 1st and 2nd heart sound, murmur (-), gallop (-)
• Pulmo : vesicular breathing sounds, rales (-/-), wheezing (-/-)
• Abdomen :
• I: flat, not distended, caput medusa (-)
• A: bowel sound 4x/minute
• P: no enlargement of liver & lien, epigastric tenderness (+), McBurney (-)
• P: timpani, shifting dullness (-)
• Extremities : warm, pitting edema (-), cyanosis (-)
CRT < 2 seconds

12. DIAGNOSTIC PLANS
RESULT NORMAL RANGE
Daily hematology:
Hb 14.6 13 - 18 g/dl
Ht 42 40 – 52 %
Erythrocyte 5.1 4.3 - 6.0 mil /ul
Leukocyte 7350 4800 - 10800/ul
Thrombocyte 284000 150000 - 400000/ul
MCV 83 80 – 96 fL
MCH 29 27 - 32 pg
MCHC 35 32 – 36 g/dL
LAB EXAM (6/4/16)

13. RESULT NORMAL RANGE
Ur 24 20-50 mg/dL
Cr 1.0 0.5-1.5 mg/dL
GDS 96 <140 mg/dL
Electrolyte :
Na 135 135 – 147 mmol/L
K 4.1 3.5 – 5.0 mmol/L
Cl 103 95 – 105 mmol/L

14. RESUME
The patient, female, 48 y.o., complained of having
nausea since 1 day prior to admission. Epigastric pain (+),
vomiting (+) 5 times containing food, lost of appetite (+),
weight loss (+) 7 kgs, past history of the same symptoms 1
month ago (+). Physical exams revealed epigastric
tenderness (+). Lab exam revealed no abnormal findings.

15. PROBLEM LIST
• Dyspepsia

16. ASSESSMENT
1. Dyspepsia
Anamnesis: nausea, vomiting, lost of appetite, weight loss 7kgs
in 1 month, past history of same symptoms 1 month ago
Physical examination: epigastric tenderness (+)
• The patient is considered of having organic dyspepsia dd
functional dyspepsia. She had epigastric pain, which is one of the
typical dyspepsia clinical manifestation according to ROME III.
• There was complaint of having weight loss 7 kgs in a month,
which is one of the alarm sign of uninvestigated dyspepsia. It is
most likely an organic dyspepsia, and the patient should be
considered to undergo endoscopic exam (ACG).
• The symptoms didn’t last for 3 months, or at least 6 months prior
to diagnosis, so it is less likely for the patient to have functional
dyspepsia. However, it can’t be ruled out yet.

17. Approaches to Uninvestigated Dyspepsia

18. • Diagnostic Plan
- Endoscopic procedure
• Therapeutic Plan
IVFD NaCl0,9% 500cc/8 hours
Diet: soft food 1700 kcal/day
Omeprazole 1 x 40 mg IV
• Education Plan
- Avoid foods or drinks that can trigger gastric acid
production (spicy or sour food, soda, coffee, tea,
alcohol)
- Small frequent feeding

19. SUMMARY
• Patient, 48 y.o., complained of having nausea since 1 day
prior to admission. The patient is currently diagnosed as
dyspepsia. She is being treated with soft food 1700
kcal/day, IVFD NaCl 0,9% 500 cc/8 hours, and
omeprazole 1x40 mg IV.
• Short term goals:
• - eliminate symptoms (pain, nausea, vomiting)
• - find the causal of dyspepsia
• Long term goal:
• - prevent recurrent symptoms
• - prevent complication

20. PROGNOSIS
• Qua ad vitam : Bonam
• Qua ad functionam : Dubia ad bonam
• Qua ad sanationam : Dubia ad malam

21. THANK YOU