dr ty all

8/13/2019 dr ty all

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ID : Mr AM / 51 yo / driver

Chief complain : body felt weak

Recent history

since 3 days ago the patient feel the body feels weak, is felt throughoutthe body, continuous, increases with activity and decreases with rest,

fatigue is not relieved by feeding, accompanied by blurry vision,

especially when posos change from sitting to standing or activity, along

with swollen and bleeding gums complaints perceived intermittent,

embossed with activity and decreases with rest, bruises arising in noskin, no pain swallow, no ears, no bleeding, no chest pain, no hot body,

shortness of no breath, coughs and colds as well not exist. no nausea

and vomiting. urinate 6-8 times / day @ 1/2-1 cup starfruit, canary

yellow, pain during urination (-). 1-2 bowel movements once a day, soft

consistency, mucus blood (-), out bumps during bowel movements are

not perceived

Previous history : DM (-)

HT (+) not routin control

8/13/2019 dr ty all


Physical Examination7

Moderate sick, underweight nutrition, compos mentis

Common Conditions:

Vital Sign :

BP : 150/90 mmHg

pulse : 88x/mnt, reguler, isi dan tegangan cukup RR : 26 x/menit

T : 38,6 oC (aksiler)

WB : 50 kg

Tall : 155 cm BMI : 17,6 kg/m2

8/13/2019 dr ty all


JVP R+2cm,Limfonodi

Eye : pale conjungtiva (+/+), sclera icteric (-)

Oedem (-/-)

THX:, normochest, chest retraction (-), pain

of sternum (-)

Cor :

I. IC appear

P. IC palpate SIC V 1 cm medial LMCS,

heavy

P. Configuration is not widen

A. HS I-II reguler, mumur(-) gallop (-)

AbdomenI. AW same as heigh CW,

A. Peristaltic sound (+) normally

Pe. Thympani, traube area thympani

Liver span 8 cm,

Pa. Soefel, tenderness(-)

H/L not palpable

back side pulmo:

I. Movement of the chest simetric

P. Fremitus left = right

P. sonor/sonor

A. Basic sound : right vesicular normal

left vesicular normal

complem entary : (-)

Front side pulmo:

I. Movement of the chest simetric

P. Fremitus left = right

P. sonor/sonor

A. Basic sound : right vesicular normal

left vesicular normal

complem entary : (-)

8/13/2019 dr ty all


8/13/2019 dr ty all


Rontgen16

Foto thorax PA position, hard enough, inspiration enaugh, can still

distinguish soft and hard tissue, the trachea in the middle, parenkim

kiri tampak infiltrat, Cast: CTR <50%, the angle of taper

costophrenicus right and left, between the ribs is not widened,

elevated diaphragm (-)

Conclusion: lung infection

8/13/2019 dr ty all


8/13/2019 dr ty all


8/13/2019 dr ty all


• Conclusion:

– Sinus ritmic, with heart rate 84 bpm,

ischemic inferior

ECG

• Sinus Rhythm

• QRS rate : 84 bpm

• Axis : Normoaxis• P Wave : normal

• PR interval : 0,16 s

• QRS duration : 0,08

• ST segment :isoelectric

• Inversion T wave :lead II, III, aVF, V1.

• LVH/RVH : -

8/13/2019 dr ty all


8/13/2019 dr ty all


Periferal blood apperance

Eritrosit : Normokrom, normosit,

anisositosis, mikrosit, sel eritroblast(-)

Leukosit : increase number, sel blast(-)

Trombosit : decrease, flat

Conclusion : anemia normokrom

normositik, leukositosis with

trombositopenia suspec Leukemia

8/13/2019 dr ty all


Problem I18

Hematology malignancy Ass : ALL

AML

IpDx : DR2, PT, APTT, Reticulosit, Feces routine BMP

IpTx : Partial Bedrest

Diet rice 2100 Kkal,

IVFD RL20 tpmBlood transfusion PRC 1000 cc 500 cc/ a day

Vit Bplex 3x1

IpMx : DR3 post transfusion, bleeding

IpEx : education patient and his family about his disease andcomplication

8/13/2019 dr ty all


8/13/2019 dr ty all


Follow Up

06.00

S : fatigue (+)

O : compos mentis, moderate sickness

TV : T :100/70 RR : 20 x/menit

N : 78 x/menit t : 36,5

8/13/2019 dr ty all


THANK YOU

8/13/2019 dr ty all


Klasifikasi Anemia Berdasarkan Morfologi dan Etiologi

Anemia mikrositik hipokromik:

1. anemia defisiensi besi

2. thalasemia mayor

3. anemia sideroblastik

4. anemia akibat penyakit kronis

Anemia normositik normokromik:

1. anemia pasca perdarahan akut

2. anemia aplastik

3. anemia hemolitik didapat4. anemia akibat penyakit kronik

5. anemia pada gagal ginjal kronik

6. anemia pada sindrom mielodisplastik

7. anemia pada keganasan hematologik

Anemia makrositik:

1. anemia defisiensi asam folat2. anemia defisiensi B12

3. anemia pada penyakit hati kronik

4. anemia pada hipotiroidisme

5. anemia sindrom mielodisplastik

8/13/2019 dr ty all


Kriteria Anemia

WHO menetapkan cut off point anemia antuk keperluan penelitian

lapangan seperti terlihat pada tabel 1.

Tabel 1. Kriteria Anemi Menurut WHO

Kelompok Kriteria Anemia (Hb)

Laki-laki dewasa < 13g/dl

Wanita dewasa tidak hamil < 12g/dl

Wanita hamil < 11g/dl

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dr ty all