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