CASE REPORT

Immune Thrombocytopenic Purpura

By : Putuhana septiani
Advicer : dr. Irman Sp.A

Patient identity

Name
: An. D
Age :2 year 6 mount
Sex : male
Address : Jati sawit
Mothers patient : Ny H
Age : 25 year
Address : jati sawit
Occupation : house wife

History taking
Main complain : Red spots in the whole body
patients come to the hospital emergency
department waled on 8-8-15 . with complaints red
spots appear all over the body suddenly , fever - ,
nausea - Mutah - , bleeding gums - , epistaxis - ,
good appetite , patients living in densely
populated areas and close to the park . The
environment around the house there is no fever
and complained of the same thing . Only this time
the patient complained of a moment like this

Past medical histoty

Common cold
varicella at the age of 10 days

family history
Not thing

Treatmen history
Not thing

Immunization history
Hepatitis B 3x, polio 3x , BCG 2x, DPT
3 x . Campak 2x

Physical examination

General state
: good
Blood pressure : 100/70 mmHg
Pulse
: 100 x / minute
Respiration
: 30 x / minute
Temperature
:36,5 C
Weight
: 11 kg
Height
: 82 cm

 Nutrion status :
BMI /age
: 1 persentil
Height /age : -1 persentil

Head
Form: Normocephal.
Eyes: periorbital edema. conjunctiva are not
edematous, Conjunctiva are not anemic, sclera not
icteric.
Nasal : within normal limits, and no secret
Ears: within normal limits
Mouth: within normal limits, the tooth are not decay
Neck : within normal limits
Thorax : Symmetryc with good expantion
Intercostal retraction (-)
Lung : Breath sounds vesicular right = left, not
cracles, not wheezing and rhonchi
Heart : S1, S2 reguler rhytm, no murmurs and no
gallop

Abdomen
Is soft, non-tender, non-distended and
without masses, fluid wave (-) shifting
dullness (-). Bowel sound (+) within normal
limits.
Liver : non palpable
Lien : non palpable
Extremites Skin
Oedem
CRT < 2 petechiae
in the
whole
body

Differential diagnostic
- Immune Trobocytopenic purpura
- Purpura henoch schonien

Further diagnostic
Blood tests
9-8-15 Hb 93 , leu 11,700, tro 16000,
ht 30%
10-8-15 Hb 10,2, leu 9300, tro 5000,
ht 20 %
11-8-15 Hb 9,7 , leu 9,8, tro 4 rb, ht
29%

Working Diagnostic
Immune Trobocytopenic purpura

Management
Infusion Nacl 9%
3 cc/KgBB/hour
Prednisolon 1,0 -1,5 mg/kgBB/day
until 2 weak

 Thaks you