Anemia Aplastik,Cva

7/28/2019 Anemia Aplastik,Cva

1/15

Morning Report

Wednesday,July 4th 2012

DM; Desi RahmaniarSeevaretnam V

Moderator:dr. Didi Chandradikusuma, Sp.PD


2/15

SUMMARY OF DATA BASE

Mr S/ 15 yo/W 25

Chief complaint : general weakness and pale

Patient suffered from general weakness since 1 month beforeadmission and worsening in last 5 days, so he could not do his

daily activity. Patient went to puskesmas and tested his bloodand was diagnosed as anemic and referred to RS Paru Batu.

At RS Paru Batu, patient was transfused with 2 packs of PRC,after transfusion patient suffered from fever. Px has mild fever

up to this moment.Px also passed black-tarry stool 1 time, about half glass. He alsofelt nausea,

Post transfusion, patient was 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 haematome since a week ago.

History of drug/alcohol consumption (-)History of chemical contact and radioactive contact(-)

Family history of cancer, bleeding (-)


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 Symmetric SF D=S , Au V V, Rh - - Wh - -V V - - - -V V - - - -

Abdomen Flat, Supple, Liver span 12cm, traube space dullness,RT : Melena +

Extremities Anemic (+), Edema (-) petechie (+), Cool acrals, CRT>2


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 - 90

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

Diff count

Eo/Ba/N/Li/Mo :0/0/14.3/83.3/2.4


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 (+)Traubes 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 CLL

Bloodsmear,LDH,BMP

O2 2-4 lpm NCIVFD NS 0,9%20tpmHigh Calory HighProtein DietTC tranfusion 4packsInj Filgrastim 300mcg SC

Ceftriaxone 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: 420

2. Melena 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 =)

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Anemia Aplastik,Cva