Algorithm approach is very important to diagnose Melena. Proper diagnosis and prompt treatment is needed

1. DUTY REPORT
Melena et causa Gastritis Erossiva
Hypertension
Supervisor : Dr. dr. Soroy Lardo, SpPD FINASIM
Johanes Hansen
Yuwen Fondly Hulkyawar
Division of Infectious and Tropical Diseases
Indonesia Army Central Hospital Gatot Soebroto
Faculty of Medicine UKRIDA

2. Name : Mr. Adjis
Age : 80 y.o
Date of Birth : 5 May 1936
Adress : Penjaringan
Religion : Moeslem
Job : Employee
Education : Junior High School
Married

3. Anamnesis
Chief Complain:
• Black stool for a day

4. Anamnesis
History of Present Illness:
• Patients was having black tarry stool since a day ago
with a liquid consistency since 2 days ago for about 100
cc every bowel elimination. Patients Bowel elimination
was about three times a day. The patients also having
chronic abdominal pain for 20 years at the upper
abdomen, Patients vomit once a day without blood.
Patients had reduced appetite since 2 days ago. No
History of having long term use of NSAID and steroid.
The patient used to have antacid to reduce the
abdominal pain

5. Anamnesis
Past History
• Hypertension(+) since 1986
• Chronic Gastritis since 1996
• Hepatitis (-)
Family History
Hypertention (+)
DM (-)

6. Anamnesis
Drug History
• Amlodipin
• Unknown other heart drugs.
Social History
• Smoking (+) since in junior high school. 1-2
pack a day
• Alcohol (-)

7. Physical Examination
Consiousness : Compos mentis
Vital Sign
BP : 140/60 mmHg
HR : 70 x / minute, regular
T : 36.5 0C
RR : 19x / minute

8. Physical Examination
Head : Normocephal
Hair : No Lession
Eye : Pupils round and symmetric, reactive to
light, conjunctival pallor -/-, jaundice -/-, nystagmus -/-
strabismus -/-
Nose : Smell Intake, Turbinate pink, no discharge
Ears : Symmetric. Tragus, anti-tragus, and pinna
free of abnormalities, canal patent drums intact
Throat : No Exudates, no erythema, no swelling.
Mouth : No sores or ulcers, teeth (-)
Neck : No Palpable lymph nodes

9. Physical Examination
Thorax (Lungs)
Inspection: Symmetric while breathing
Palpation : Vocal fremitus right = left
Percussion: resonant sound bilaterally
Auscultation: Vesicular bilaterally(+), Rhonki (-),
wheezing (-)

10. Physical Examination
Thorax (Heart)
Inspection : No Visible Ictus cordis
Palpation : Ictus cordis at ICS 5 linea midclavicula sinistra
Percussion : Normal
Auscultation: Normal S1-S2 are heard, murmur (-), gallop
(-)

11. Abdomen
Inspection : Normal Countour
Auscultation : increasing bowel movement
Palpation : No palpable masses, pain when
palpating epigastrium region
Percussion : Shifting dullness (-)

12. • Rectal Touche
– Sfingter Ani  <<
– Ampula  not collapsed
– no masses at palpation
– No pain at palpation
– Prostate getting hypertrophy approximately 5 cm
– No blood after doing rectal touche

13. Labs
Examination Result
Hb 12,2* 13 – 18 g/dL
Ht 36* 40 – 52 %
Eritrosit 4.1 4,3 – 6,0 juta/uL
Leukosit 4030 4800 – 10800 / uL
Trombosit 246.000 150000 – 400000 / uL

14. Labs
Examination Result
MCV 89 80 – 96 fL
MCH 29 27 – 32 pg
MCHC 32 32 – 36 g/dL
• Ureum 21 20-50 mg/dl
• Creatinine 0.8 0,5-1,5 mg/dl
• Blood Glucose 92 <140 mg/dl

15. Labs
Examination Result
Natrium 143 135 – 147 mmol/L
Kalium 4.0 3.5 – 5.0 mmol/L
Cl 109* 95 – 105 mmol/L

16. Problem List
1. Melena et causa Gastritis Erossiva
2. Hypertension

17. Black Tarry Stool
Anamnesis Physical Examination
Laboratory
Result
Labs shows
minimally
increase of Cl,
minimally
decrease of
HB, decrease
of HT
Clinical manifestation
(acute clinical):
1. Epigastric pain (+)
2.Conjungtival pain (-)
3. Weakness (-)
4. Anorexia (-)
5. Tacicardy (-)
Chronic clinical:
1. Weight loss (-)
Drug history:
1. NSAID (-)
2. aspirin (-)
3. Antiplatelet (-)
4. Bismuth & iron (-)
5. Anticoagulant (-)
Past history:
Chronic Drug Gastritis (+)
Hepatitis (-)
Smoking (+)
Alcohol abuse (-)
Barthel Index
(Indeopendent)
Vital sign:
- BP: 140/60 mmHG
- HR: 70 x/mins
- RR: 19x/mins
- T: 36,5
Abdomen:
- Epigastric pain
RT:
- Sfinter ani <<
- No masses
- No blood
- No Collapsed ampulla

18. Etiology a. Epigastric
errosive
b.Varises
Esophagus
c. Peptic Ulcer
Diagnosis
Treatment
Planning
maintenance
-Endoscopy
-Omeprazol
- Sucralfat
- Bed Rest
- Consume
food that
not irritate
gastric

19. Problem Solving
1. Melena et causa Gastritis Erossiva
• Anamnesis : Black tarry stool, abdominal pain, nausea
and vomitus, decreasing of apetite
• PE : Pain on palpating epigastrium area , increasing
bowel movement on auscultation
• PP : minimally increase of Cl, minimally decrease of HB,
decrease of HT
• DD: Hematemesis Melena ec Varises Esophagus
• Diagnose Plan : Endoscopy
• R/Th :
• Inj Omeprazole 1x40 mg
• Syr Sucralfat 3 X 1C

20. Resume
• Patients was having black tarry stool since a day ago with a liquid
consistency since 2 days ago for about 100 cc every bowel
elimination. Patients Bowel elimination was about three times a
day. The patients also having chronic abdominal pain for 20 years at
the upper abdomen, Patients vomit once a day without blood.
Patients had reduced appetite since 2 days ago. No History of
having long term use of NSAID. The patient used to have antacid to
reduce the abdominal pain
• Physical examination shows pain at palpating epigastrium area
and increasing bowel movement
• Labs shows minimally increase of Cl, minimally decrease of
HB, decrease of HT

23. Prognosis
• Quo ad Vitam : Dubia ad bonam
• Quo ad Functionam : Dubia ad bonam
• Quo ad Sanationam : Dubia ad bonam