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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
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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.
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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 (-)
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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 (+)
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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%
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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
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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
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chest x-rays
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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
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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
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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
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Condition this morning
BP : 110/70 mmHg
N: 82 tpm
RR: 18 tpm
Tax : 38 C
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Thank you