1.

1 Background

Immune Thrombocytopenic Purpura (ITP) is an autoimmune disease in which

antibody binding with platelet antigen results in excessive and faster platelet
destruction thus resulting in low sedentary platelet levels (<150,000 L).1,2,3
The incidence of ITP is 100 cases per 1,000,000 people per year and 50% of cases
occur in children. ITP is classified as primary and secondary based on other diseases.
Primary ITP is differentiated into acute and chronic with a 6-month time limit. Primary
acute ITP is more common in children 2-6 years of age, recovering within less than 6
months, approximately 15-20% of cases become chronic ITP. Chronic ITP often occur
in adults with a median age of 40-45 years.1,2 Incidence of ITP in children between 4 -
5.3 case per 100,000 people. The incidence of chronic ITP in children is estimated to
be 0.46 case per 100,000 children per year.2

ITP often manifests clinically as tendency to bleeding, including purpura and

petechiae (extravasation of blood from capillary blood vessels to the skin and mucous
membranes).3 Spontaneous bleeding on mucosal, intracranial, and gastrointestinal may
occur at platelet levels below 10.000 L.

Diagnosis of ITP is based on history taking, physical examination, laboratory

findings in platelet count, and peripheral blood smear examination. In ITP showed low
number of platelets count but with normal size, observable giant platelets, with normal
morphology in erythrocytes and leukocytes. Antitrombocyte antibody assessment
supports the diagnosis of ITP.3

Management of ITP based on platelet level and severity of bleeding, can be

differentiated into pharmacological and surgical therapy. In Pharmacological therapy
first choice is the using corticosteroids, intravenous immunoglobulin, and intravenous
Rh anti-D. The second preferred pharmacological therapy is immunosuppressant and
rituximab used when the patient is intolerant to first-choice pharmacological therapy.
Surgical therapy was performed with consideration of, among other things, severe
menorrhagia, life-threatening hemorrhage, and limited daily activities of life.4

1.2 Goals

The purpose of this report is to know how to diagnose, manage the patient
comprehensively and holistic according to the standard of competence based on data
obtained from medical history, physical examination, investigation, and literature and
to know the prognosis of ITP patients with good nutrition and normal stature.

Curent medical History

Since the age of 5 years, the patient has a recurrent nosebleed and vomiting 5-8x a day,
limp (+), pale (+),red spots on the skin (-) so treated at Tugu Hospital and got
transfusion 2 red blood bags. The doctor said the patient suffered from dengue
hemorrhagic fever and typhoid, then was allowed to go home. Then the patient
hospitalized in Tugu Hospital 3 times with the same complaint, because no recovery,
patient then referred to RSDK. In RSDK patients are said to suffer from blood disorders
ITP. Patients underwent treatments given blood transfusions and methylprednisolone.
Then the patient is often hospitalized at RSDK 3x / year.
When the patient is 14 years old, the first menstrual period is 3 weeks, change pads 4-
5 times daily, the blood that comes out in the form of fresh blood and blood clots, limp
(+), pale (+). The patient then hospitalized in RSDK and said this was due to ITP's
disease. At the age of 15 years, patients menstruated for 2 weeks, replace the pads 4-5
x daily, limp (+), pale (+). The patient was then treated in RSDK and said this was due
to ITP's disease. Patients were given blood transfusions and methylprednisolone.
2 weeks before hospitalized, patient has menstrual period, change pads 4-5 times a
day, blood coming out in the form of fresh blood and sometimes blood clots. limp (+),
pale (+), mild fever (+), nausea (-), vomiting (-), feeling hard to breathe, nosebleeds
(+) 1x with small amount of blood and stops itself, red spots on skin (-). Patients then
go to ER RSDK.
When in the ER RSDK, the patient out the spots from the birth canal, limp (+), pale
(+), fever (+) 38.60C, chest not feeling well when breathing (+), spontaneous bleeding
(-) and it is said to be chronic ITP. Patients obtained O2, infusion, Paracetamol, red and
yellow blood transfusions due to blood lab results showed gravis anemia (Hb: 1.6 g /
dL), leukopenia (5,200 / mmk), and thrombocytopenia (14,000 / mmk). After
transfusion, patient lab results still showed moderate anemia (Hb: 6.9 g / dL),
leukocytosis (17.600 / mmk), and thrombocytopenia (16.000 / mmk). The patient is
then admitted to the 1st floor child nursery ward. In the ward, the patient receives a red
and yellow blood transfusion and a methylprednisolone injection. After transfusion,
the patient lab results showed mild anemia (Hb: 10.7 g / dL), leukocytosis (14.100 /
mmk), and thrombocytopenia (15,000 / mmk).
Currently the patient is not weak, pale (-). Patients discharged.

Past medical history

History of Immune Thrombocytopenic Purpura since the age of 5 years.
History of last blood transfusion 1 year ago in RSDK.
Parents suffering from HIV are denied.

Socio-Economic History
Father works as a laborer with an income of 750.000-1.500.000 rupiah / month.
Mother as a housewife. Bearing 2 children who are not financially independent, 1
child graduated from junior high school and 1 child graduated from elementary
school.
The location of the house close to the SUTET, gardens, and rice fields is undeniable.
Financing treatment using Jamkesmas.
Impression: socioeconomically low.
Criteria for Socio-Economic by BPS (Central Bureau of Statistics)
BPS Criteria : Total score <10 = poor, total score 10 = not poor. This
family belongs to poor families according to BPS criteria.
Conclusion : Poor family according to BPS.

2.1 Specific data

Prenatal Maintenance History

History of infection during pregnancy is denied, history of seizures during pregnancy
is denied, history of premature rupture of membranes is denied, history of high fever
is denied. When pregnant, the mother does not consume raw food and consumes only
one food that is burned like a satay. Mom does not take pets.

Postnatal Maintenance History

After the birth of the child is checked into the puskesmas, the child is healthy.
Children do not regularly control to Posyandu, only during immunization only. The
history of seizures is denied, the history of trauma is denied

Immunization History
BCG : 1 time (2 months)
DPT : 3 times (2,3,4 months)
Polio : 4 times (0,2,3,4 month)
Measles : 1 time (9 months)
Hepatitis B : 4 times (0.2,3,4 months)
Impression : Completed basic immunization according to age. Booster (-)

Eating and Drinking Children

4 - 7 months : breast milk, formula milk, bananas 2x a day, 2x daily nestle
porridge 10-20 small spoon
7 months - 1 year : breast milk, formula milk, bananas 2x daily, rice + family
meals 3x daily plate
1 year - 2 years : formula milk, banana 2x daily, rice + family meals 3x daily
plate
2 years - now: rice + family meals 3x a day 1 plate
Impression : Breastfeeding not given exclusive, complementary feeding
too early, less quality, adequate quantity.

Tabel 1. Food Recall

Day Morning Afternoon Night

I rice, oseng tempe, rice, oseng tempe, rice, oseng tempe,

sayur bening fried tofu
egg

II rice, fried tempe, rice, ca taoge, rice, fried catfish,

crackers saltened fish ca taoge saltened
fish

III Fried rice, kerupuk Fried rice, 1 piece rice, fried tofu,
of chicken, sayur sayur asam
asam

Nutrition Status and Development

Anthropometric Measurements (May 25, 2017)
Birth Weight = 2.9 kg
Last month's weight = 48 kg
Current weight = 46 kg
Birth body length = 48 cm
Current Height = 151 cm
Genitalia
Inspection: Labium major and labium minor within normal limits, redness (-),
lacerations (-)
Palpation: Tender (-), mass (-)
Rectal toucher: sufficient sphincter anal tone, slippery mucosa, cavity uteri of chicken
eggs, not palpable mass in adnexa

2.6 List of Problem

No Active problem Date No Passive problem date

1. Severe anemia 22/5/2017 1. Inefficient 22/5/2017
2. Leukocytosis 22/5/2017 peripheral
3. Thrombocytopenia 22/5/2017 perfusion
2. Bleeding risk 22/5/2017

2.7 WORKING DIAGNOSE

1. ITP

2. Severe anemia after transfusion

3. Good nutrition, normal body posture

2.8 INITIAL PLAN

1. Assesment : ITP
Ip Dx : S : -

O :-

Rx :
- Methylprednisolone injection 4 mg/kgBB/day
- O2 nasal lpm
 - Infusion D5 NS 720/30/8 tpm
Mx :

- Evaluation of general condition, vital sign (blood pressure, heart rate,

temperature, respiration rate), sign of bleeding
Ex :

- Explaining to the patient parents about patient disease and

management.
- Explaining to the patient parents about dosage and how to administer
drug.
2. Assessment : severe anemia after transfusion
Ip Dx : S : -
O : routine blood laboratory
Rx : PRC transfusion 3 unit
Mx :
- Evaluation of general condition, vital sign (blood pressure, heart rate,
temperature, respiration rate), sign of bleeding.
- Evaluation of transfusion reaction that might happen.
Ex :
- Explaining to the patient parents about the procedure of transfusion
and why it should be done.
- Explaining to the patient parents about the transfusion reaction that
might happen.
3. Assessment : good nutrition, normal body posture
Ip Dx : S : -

O : diet acceptability

Rx :

Ideal weight : 42 kg
Mx : diet acceptability, monitoring patient body weight

Ex :

- Explaining to the patient parents about how important body weight

and body height according to age with dietary intake that fulfill
daily nutritional needs.
- Educate to the patient parents to follow dietary pattern that have
been designed so that the growth of children can rise and not goes
down.
- Motivate parent to maintain adequate dietary provision to keep
children growing well
2.9 PROFILE PLACE TO STAY

House situation

Home statues : privately owned

Size : 8x3 m2

Occupant : 4 people

Terrace house : none

House wall : wall

Floor house : ceramics

Room : 1 bed room, kitchen, bathroom, and living room

Bathroom : privately owned

Drinking water source : artesian well

Wash water source : artesian wall

Ventilation : there is 1 window in the living room and there is 1

door. The door is opened in the morning and afternoon.

Kitchen : behind the house, close to the bedroom. The cooking

family uses LPG stoves with no ventilation.

Dustbin : trash is collected in plastic and dumped in front of the

house. No officer picks up trash. Garbage is burned
every 3 days

Water reservoir : Water reservoir in bathroom, water barrel for cooking

needs