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    Duty Report July, 26 2017: Coass: Nodya Melinda Noori Succi Islam

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    Rahadian Malik
    1. A 34-year-old female presented with fatigue for 3 months and worsening symptoms for the past 2 weeks including decreased appetite and weight loss. 2. Physical examination revealed pale lips, nails, and conjunctiva as well as stomatitis and purpura on the extremities. 3. Laboratory results showed pancytopenia with anemia, leukopenia, and thrombocytopenia.

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    Duty Report July, 26 2017: Coass: Nodya Melinda Noori Succi Islam

    Uploaded by

    Rahadian Malik
    51 views22 pages
    1. A 34-year-old female presented with fatigue for 3 months and worsening symptoms for the past 2 weeks including decreased appetite and weight loss. 2. Physical examination revealed pale lips, nails, and conjunctiva as well as stomatitis and purpura on the extremities. 3. Laboratory results showed pancytopenia with anemia, leukopenia, and thrombocytopenia.

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    Duty Report

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    1. A 34-year-old female presented with fatigue for 3 months and worsening symptoms for the past 2 weeks including decreased appetite and weight loss. 2. Physical examination revealed pale lips, nails, and conjunctiva as well as stomatitis and purpura on the extremities. 3. Laboratory results showed pancytopenia with anemia, leukopenia, and thrombocytopenia.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    51 views22 pages

    Duty Report July, 26 2017: Coass: Nodya Melinda Noori Succi Islam

    Uploaded by

    Rahadian Malik
    1. A 34-year-old female presented with fatigue for 3 months and worsening symptoms for the past 2 weeks including decreased appetite and weight loss. 2. Physical examination revealed pale lips, nails, and conjunctiva as well as stomatitis and purpura on the extremities. 3. Laboratory results showed pancytopenia with anemia, leukopenia, and thrombocytopenia.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 22

    Duty Report

    July, 26th 2017

    Coass :
    Supervisor : dr. Soroy Lardo, Sp.PD FINASIM
    Nodya Melinda Noori
    General Practitioner : dr. Septa Tio Emeralda
    Succi Islam

    DEPARTEMENT OF INTERNAL MEDICINE


    INDONESIAN ARMY HOSPITAL CENTRE GATOT SOEBROTO
    Anamnesis

    Chief Complaint :
    fatigue since 2 weeks before
    came to hospital
    Mrs. NM
    34 yo

    Moeslem
    Patient identity married

    House wife
    JL. Hj. Uung RT 003/007
    History of recent illness
    2 weeks BC2H
    3 months Fatigue
    ago Getting heavier, especially when patient walking for
    about 20 meters.
    fatigue Feels pale on face and hands
    Decrease appetite
    Red spot appear on hands and legs
    Bleeding (-)
    History past ilness Family history Treatment history

    Paracetamoll
    Allergic (-) HT (-), DM (-),
    HT(-) malignancy
    DM (-) hematologi
    Malignancy (thalassemia,
    transfusion anemia)
    Physical Examination
    General state : mild illness Height : 156 cm
    Consiousness : Compos mentis Weight : 48 kg
    BMI : 19.88 kg/m2
    Vital sign : (Normoweight)
    BP : 90/70 mmHg
    HR : 80 x/menit, reg.
    RR : 20 x/menit
    T : 37,3oC (axilla)
    Head : Normocephal, normal head distribution
    Eye : Anemic Conjungtiva +/+, Sclera icteric -/-
    Ear, Nose, Throat : no abnormalities, epistaxis (-)
    Mouth : Pale lips (+), Stomatitis (+)
    Neck : lymph node enlargement (-), JVP 5-2 cmH2O
    Cor Pulmo
    Inspection : No visible ictus cordis Inspection : normal chest shape,
    Palpation : Ictus cordis at ICS 5 linea Symmetric while breathing, no retraction
    midclavicula sinistra of intercostae space
    Percussion Palpation : symmetric tactile fremitus,
    Left margin : ICS V linea left midsternalis symmetric chest expansion
    Right margin : ICS V linea left mid clavicle Percussion : Resonant sound bilateraly
    Upper margin : ICS IV linea left (sonor)
    parasternal
    Auscultation : Vesicular breathing sound
    Auscultation : Normal S1-S2 are
    bilaterally (+), Rhonki (-), Wheezing (-)
    heard, murmur (-), Gallop (-)
    Abdomen

    Inspection : normal countour, caput medusa (-)


    Auscultation : normal bowel movement
    Palpation : no palpable liver and spleen, no pain when palpating all
    abdomen region, normal turgor
    Percussion : tympanic in all area, Shifting dullness (-), icterus (-)

    Extremity :
    Cold acral, Pale Nails (+), CRT >2s
    Purpura at ekstrimitas superior and inferior (+)

    Rectal Touche : no blood signs


    Laboratory
    Result
    Hemoglobin 6.8** 13.0 - 18.0 g/dL
    Hematokrit 21* 37 47 %
    Eritrosit 3.1* 4.3 6.0 juta/L
    Leukosit 1130** 4,800 - 10,800 / L
    Trombosit 110.000* 150,000 400,000 / L
    MCV 69* 80 96 fL
    MCH 22* 27 32 pg
    MCHC 32* 32 36 g/dL
    RDW 19.50* 11.5 14.5 %

    Natrium (Na) 136 135-147 mmol/L


    Kalium (K) 3.7 3.5-50 mmol/L
    Klorida (Cl) 98 95. 105 mmol/L
    Resume
    Fatigue 3 months,
    more heavier in 2
    weeks
    Myalgia (+), weight On physical examination
    loss of about 5 kg
    CA +/+, pale lips and nail, stomatitis
    Mrs.NM (+) lesi eritem mukopapular <1x1cm
    34 yo upper and lower extremity

    Laboratory result:
    Anemia, leukopenia, trombositopenia
    Problem list

    1. Obsrv Pansitopenia
    Problem Solving
    Observ. Pansitopenia

    Anamnesis : lemas yang sudah dirasa sejak 3 bulan dan semakin


    memberat, nafsu makan berkurang, berat badan menurun,
    stomatitis.
    Pemeriksaan fisik : CA +/+, bibir pucat, kuku jari tangan kaki pucat. Stomatitis
    (+), purpura (+)
    Pemeriksaan penunjang : Lab darah anemia, leukopenia, trombositopenia
    pansitopenia
    Rencana diagnostik : morfologi gambaran darah tepi, SI, TIBC, Feritin, ro thorax
    serologi HIV
    Rencana terapi : transfuse PRC.
    Prognosis
    Quo ad vitam : dubia
    Quo ad functionam : dubia
    Quo ad sanationam : dubia
    1. Davies J. Assesment of pancytopenia. Journal:
    BMJ Best Practice. 2016 Dec.
    Etiology
    Decreased production of blood cells or bone marrow
    failure,
    Defective stem cells,
    from their immune-mediated destruction or non-immune-
    mediated sequestration in the periphery,
    Deficiency of factors stimulating haematopoiesis

    1. Davies J. Assesment of pancytopenia. Journal: BMJ Best Practice. 2016 Dec.


    Weinzrl E, Arber D. The differential Diagnosis and Bone Marrow Evalution of New-Onset Pancytopenia. Journal: American Jurnal of Clinical Pathology. 2013 Jan;139(1):9-29
    References
    Weinzrl E, Arber D. The differential Diagnosis and Bone Marrow
    Evalution of New-Onset Pancytopenia. Journal: American Jurnal of
    Clinical Pathology. 2013 Jan;139(1):9-29
    Bhasin P. Approach to a Case of Pancytopenia. Journal: The American
    Journal of Medicine. 2008 Jan; 69:177-182
    Davies J. Assesment of pancytopenia. Journal: BMJ Best Practice.
    2016 Dec

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