MYELODySPLASTIC SYNDROME

Case dr. Arif Gunawan, Sp.PD

Tiara Rahmawati030.08.240

• Mrs. DName• 24 years oldAge • femaleSex • Adiarsa, Karawang Address

• Senior High SchoolEducation • HousewifeOccupation • IslamReligion • MarriedMarital status• July 10th 2012Admitted • Teluk JambeTaken from

IDENTITY

PICTURE OF THE PATIENT

ANAMNESIS

Autoanamnese on July 11th 2012 at 13.30

CHIEF COMPLAINT

Bleeding gums since 3 days before hospitalized

ADDITIONAL COMPLAINT

• Black and bloody excrements

• Nausea• Black vomiting• Loss of appetite

• Headache• Ptechiae in both hands and

feet• Fainting

ANAMNESIS

HISTORY OF PRESENT DISEASE

Patients came to the Emergency Unit of RSUD Karawang with complaints of gum bleeding since 3 days before hospitalized. Occurring continuously, with dark red in color. Patient denied of having a toothache.

The patient also suffers black and bloody excrements that had occurred since 3 days ago. Defecation occurred intermitten, and its excrement black in color with soft consistency and there were no phlegm detected.

Patients also suffers nausea and vomiting since 2 days before hospitalized. 2 times a day, can fill up to one aqua botol in volume, and consisted of fluid ingestion, yellow in color, with absence of blood, and without squirting. So, the patient loss her appetite.

HISTORY OF PRESENT DISEASE

On the hands and feet of patients out of red spots from 2 days before hospitalized. 1 day before hospitalized, the patient had fainted due to fatigue.

The patient denied any nosebleed, trouble breathing or coughing, and no disturbance in urination. The patient said that her menstrual cycle is once a month. Every day using a 5 pampers, no longer using pads.

APLASTIC ANEMIA (+)

was diagnosed

6 years ago

GASTRITIS

( + )

DIABETES

( - )

KIDNEY DISEASE

( - )

ASTHMA

( - )

HYPERTENTION

( - )

HISTORY OF PAST DISEASE

SAME DISEASE

( - )

HYPERTENSION

( - )

DIABETES

( - )

KIDNEY DISEASE

( - )

ASTHMA

( - )LEUKIMIA/BLOOD

DISORDER (-)

FAMILY HISTORY

• The patients received trombocyte or PRC transfusions every month

• And taking folic acid and vitamin B12 three times a day in 6 years

MEDICATION HISTORY

PERSONAL AND SOCIAL HISTORY

No consumption

of herbal drink

No smoke, no consumption of alcohol or

drugs

Seldom

exercise History of exposure to chemicals or toxic denied

General condition

General appearance • moderately ill

conciousness

• Compos mentis

Height

• 165 cm

Weight • 55 kg

BMI

• 20,2kg/m2

VITAL SIGN

Vital sign

BP:

110/50mmHg

RR

16 times/minute

HR:

80 times/minute

Temp:

36 °C

PHYSICAL EXAMINATION

• NORMOCEPHALY

HEAD

• ANEMIC CONJUCTIVA +/+• ICTERIC SCLERA -/-

EYES

• LYMPYH NODE IS NOT PALPABLE• THYROID GLAND IS NOT PALPABLE

NECK

• LIP : DRY (+), PALLOR ( + ), CYANOSIS ( - )• GUMS : BLEEDING (+)

MOUTH

THORAXHEART

INSPECTION

• Ictus cordis is invisible, spider nevi (-)

PALPATION• Ictus cordis is palpable at 5th ICS LMCS

PERCUTION• Right heart border: ICS III-V LSD• Left heart border: ICS V 1cm medial LMCS• Upper heart border: ICS III LPSS

AUSCULTATION• Regular I - II absence of murmurs and gallop in

heart’s sound

Lung Examination

THORAX

I : Symmetrical Pal : Equal vocal resonancePer : Sonor in both lungsA : Vesicular breath sound in both

lung,ronchi (-/-),wheezing (-/-)

Inspection Brown skin, distended abdomen, icteric (-), caput meducae (-)

Palpation No Pain on palpation at Epigastric Liver not palpable Spleen not palpable Shifting dullness (-)

Percussion No pain present on abdominal percussion Dullness CVA (-)

Auscultation Bowel sound (+) 2 times/minute. Arterial bruit (-), venous hum

(-)

ABDOMINAL EXAMINATION

Extremity ExaminationExtremity examination

WARM ACRALS

OEDEM

PTECHIAE

+ +

+ +

- -

- -

+ +

+ +

LABoratory findings

Test Result Normal values

Hb 5,6 (12 – 17) g%

HT 16 (37 – 48) %

Leukocyte 6200 (5000 – 10000) /ul

Trombocyte 23.000 (150.000 – 450.000) /ul

Laboratory FindingsJuly 10th 2012 Patient result Normal range

Basophil 0 0-1%

Eosinophils 0 1-3%

Band Neutrophils 0 2-6%

Segmented Neutrophils 71 40-70%

Lymphocyte 26 20-40%

Monocyte 3 2-8%

MCV 81 82-91 cu µm

MCH 29 27-31Pg/cell

MCHC 36 32-35 hb/cell

RDW 14 11,6-14,0%

Erythrocyte : Hipocrom, anisopoikilocytosis

(mikrosit, ovalosit, cigar shaped)

Leukocyte: Sufficient quantities, no pathological

shape

Thrombocyte: Decrease in total thrombocyte,

thrombocyte colony ( - ), Giant thrombocyte ( - )

Impression : thrombocytopenia with anemia

mikrositer

PERIPHERAL BLOOD SMEAR(July 10th 2012)

BONE MARROW PUNCTURE

(March 2012)

Myelodysplastic syndrome

RESUMESign & Symptoms Physical

ExaminationLaboratory and Preripheral Blood Smear

• Bleeding gums since 3 days before hospitalized

• Black and bloody excrements

• Nausea and black vomiting

• Loss of appetite• Headache• Ptechiae in both hands

and feet• Fainting

• Anemic conjuctiva

( + / + )

• Pallor and dry lips, bleeding gums

• Ptechiae on both hands and feet

Hb: 5,6 g/Dl Leukocyte : 6200Thrombocyte: 23.000 Ht : 16%

MCV :81 Hb/cellRDW:21%Diff Count Leukocyte :0/0/0/71/26/3

Peripheral blood smear:thrombocytopenia with anemia mikrositer

• MDS(Myelodisplastic Syndrome)• APLASTIC ANEMIA• ITP

DIFFERENTIAL DIAGNOSIS

WORKING DIAGNOSIS

MDS(Myelodisplastic Syndrome)

SUGGESTED EXAMINATION

KROMOSOM

LED

ESSAY FLOW CITOMETRY

THERAPY• PRC BLOOD TRANSFUSION (4 Packs)• IVFD NACL 30 drops/minute• Metil prednisolon 2x125• Dycinon 3x1• Adona /drip• Ranitidin 2x1• Ceftriaxon 2x1 gr

prognosis

Ad sanationam

dubia ad malam

Ad Fungsionam

dubia ad

malam

Ad Vitam

Dubia