Arifin 29 Mei. AIHA
Arifin 29 Mei. AIHA
Arifin 29 Mei. AIHA
Chief Complaint
Fatigue and weakness since 1 week ago.
• BP : 130/70 mmHg
• HR : 92x/minute
• RR : 18 x/minute
• T : 37,2 C
• SpO2 : 99%
• Eye VII
– Conjunctiva anemic (+/+)
– Icteric sclera(+/+)
• Neck
– JVP 5+0 cmH20
• Lung: normochest
– Inspection: symmetric right = left
– Palpation: fremitus right = left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger lateral LMCS ICS VI
– Percussion:
• Left border: 1 finger lateral LMCS ICS VI
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-), gallops (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and spleen are not palpated
– Percussion: tympani
– Auscultation: bowel sound (+) normal
• Extremities:
– Oedema -/-
Laboratory
Items Value VII
Hb 5,2 gr/dl
Ht 14%
Leukosit 5.880/mm3
Platelet 129.000/mm3
Reticulosit 22,61
Diff. Count (B/E/NB/NS/L/M) 0/1/4/65/14/10
SGOT/SGPT 38/11
PT/APTT 11,4/22,2
Ur/Cr 22/1
Na/K/Cl 138/3,6/107
RBG 106
Chest X-Ray VII
ECG VII
Problems
• Anemia
• Cardiomegaly
• PVC infrequent
Working Diagnosis