Anemia Aplastik,Camelia

7/28/2019 Anemia Aplastik,Camelia

1/15

Morning Report

Wednesday,July 4th 2012

IA : dr. Camelia, dr. Yasmita, dr. Galuh (Cardio)IB : dr. Merici , dr. Ames

II : dr. SatrioIII: dr.Didi C SpPD

Moderator: dr. Atma Gunawan, SpPD, KGH


2/15

SUMMARY OF DATA BASE

Mr/ 15 yo/W 25

Chief complaint : general weakness and pale

Patient suffered from general weakness since 1 month before

admission and worsening in 5 last days, so he could not do hisdaily activity. Patient went to public health center and gotblood check then diagnosed as anemias and referred patient toRS Paru Batu.

At RS Paru Batu, patient got 2 packs of PRC transfussion,during the transfussion patient getting fever.

He also complained of passing black-tarry stool 1 time, about glass.

He also felt nausea, then patient referred to RSSA.


3/15

Continued

There was decreasing of body weight 3kg/1 month.No history of gum bleeding, but there was history ofpetechie haematom since a week ago.

History of long time drug consuming (-)History of chemichal and radioactive contac (-)


4/15

PhysicalExaminationGeneral appearance Looked moderately ill GCS : 456

Blood Pressure 110 /60 mmHg

Pulse Rate 84 tpm

Respiration rate 20 tpm,

T ax 37.40C

Head Anemic (+), Icteric (-)

Neck JVP R + 2 cmH2O at 30 0 position

Chest Heart Ictus visible, palpable at 1 cm medial MCL S ICS VRHM SL (D), LHMIctusS1 S2 single tachycardia,murmur (-) gallop (-)

Lung Symetric SF D=S , P: S S, Au V V, Rh - - Wh - -S S V V - - - -S S V V - - - -

Abdomen Soefl , Liver span 12cm, traube space dullnessRT : Melena -

Extremities Anemic (+), Edema (-) ptechie (+)


5/15

Laboratory findings Value

Leucocyte : 450 /l N: 3.500 10.000

Hemoglobine : 5.80 gr/dl N: 11,0 16,5

MCV : 81.40 N: 80 - 97

MCH : 30.90 N: 26.533.5

PCV : 15.30 % 35 - 50

Trombocyte : 2.000 /L 150.000 390.000

RBS : 126 mg/dl < 200

Ureum : 25.90 mg/dL 10-50

Creatinine : 0.46 mg/dL 0,7 1,5

SGOT : 11 U/L 11 41

SGPT : 10 U/L 10 41

Na : 139 Mmol / L 136 145K : 3.95 Mmol / L 3,5 5,0

Cl : 111 Mmol / L 98 106

PPT 12.7 detik (K:11.6)

APTT 28.3 detik (K:28.8)Reticulocyt 0.22%


6/15


7/15

Laboratory Finding continued...Lab Value Lab Value

Urinalysis Yellow, clear 10 x

SG1.010 Epithel 0-1

6.5PH Silinder -

Leucocyte - Hialine -

Nitrite - Granuler -

Protein - Leucocyte -

Glucose - Erytrocyte

Eritrocyte - 40 x

Eritrosit 0-1

Keton urine - Leucocyte 0-2

Urobilinogen - Crystal -

Bilirubin - Bacteria Negatif


8/15

Blood Smear at RS paru batu

1. Darah tepi

HGB : 5.3 g/dL

MCV : 73.7 fl

MCH : 26.8 pg

RBC : 1.98 juta/uL

WBC : 500 sel/uL

Hapusan darah : normokrom normositer

Lekosit : kesan jumlah menurun, sel blast negatip

Trombosit : kesan jumlah sangat menurun

Conclusion : Pansitopenia curiga Anemia Aplastik


9/15

chest x-rays


10/15

CHEST X RAY

AP position, symmetric, enough KV, enough inspiration,Soft tissue and bone normal.

Phrenico costalis angle Right and Left sharp,

Right and left Hemidiaphragm dome shape

Lung : normal

Cor site N,shape N, CTR


11/15


12/15

CUE andCLUE

PROBLEMLIST

INITIALDIAGNOSE

PLANINGDIAGNOSE

PLANINGTHERAPY

PLANINGMONITORING

Male / 15 yoGeneralweakness,feverPE: palekonjungtiva.Ptechie (+)Traubs space

dullnessPale extremityLab :Hb : 5,8gr/dlEry: 1.88

jt/mm3,MCV= 81.40,MCH= 30.90Trombocyte: 2.000Leucocyte: 420Eo/Ba/N/Li/

1. Pansitopenia +Splenomegali

1.1. AnemiaAplastik1.2. MDS1.3 CLL1.4AleukemiaLeukemia

Bloodsmear,LDHBMP

O2 2-4 lpm NCIVFD NS 0,9%20tpmSoftDiet HighCalory High ProteinTC tranfusion 4packs

Inj Filgrastim 300mcg SCCeftriaxone 2x1griv skin test firstPO: paracetamol3x500mg if needed

VitalsignCBC


13/15

CUE andCLUE

PROBLEMLIST

INITIALDIAGNOSE

PLANINGDIAGNOSE

PLANINGTHERAPY

PLANINGMONITORING

Male / 15 yoblacktarrystoolPE: palekonjungtiva.Ptechie (+) RTmelena -Lab

Hb : 5,8gr/dlEry: 1.88

jt/mm3,MCV= 81.40,MCH= 30.90

Trombocyte: 2.000Leucocyte: 420Rectaltoucher:

2. HistoryMelena

2.1 due to no1

FOBT Treat underlyingdisease

VitalsignCBC


14/15

Condition this morning

BP : 110/70 mmHg

N: 82 tpm

RR: 18 tpm

Tax : 38 C


15/15

Thank you

Anemia Aplastik,Camelia

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