- The patient, a 48-year-old housewife, presented with nausea, vomiting, loss of appetite, and 7 kg weight loss in the past month with a history of similar symptoms one month ago. - She was diagnosed with dyspepsia and is being treated with soft food, IV fluids, and omeprazole to eliminate her symptoms while undergoing endoscopy to determine the cause of her dyspepsia. - The goals are to relieve her current symptoms, identify the cause of her dyspepsia, and prevent future recurrent symptoms and complications through treatment and lifestyle changes.

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