CASE REPORT

ANEMIA APLASTIC

By:
I Made Bayu Wiratama
NPM : 10700194
 Name : Bonanza
Patients Overview
6 Years Old Kid was brought by his Mother to Nganjuk Hospital
Emergency Room, after experiencing coughing with phlegm

Past Medical History

At the age of 5 years old, the patient was diagnosed with anemia
aplastic.
Because of the anemia aplastic, the patient got Blood transfusion
(PRC) in Nganjuk General Hospital.
After being hospitalized for a couple days, the patient was refferd to
Dr Sutomo Hospital Surabaya.
At Dr Sutomo Hospital Surabaya, the patient got blood transfusion
(PRC and TC) and bone marrow aspiration procedure. But the result
couldnt evaluate because she didnt have enough red blodd cell.

Pregnancy History
9 months pregnancy, the patient was born with the help of the
midwife, spontaneously with the weight 3.0 kg

Social History
the patient lives with the parents and from the middle class family
 PHYSICAL EXAMINATION
-Mental Status: compos mentis
-Weight : 15 kg
-Vital Signs = Respiration Rate: 25x/min, HR: 100x/min, T: 35.6c
- Head, Face, and Neck Examination= A/I/C/D = + / - / - / -
-Chest Examination = Auscultation : Pulmo : Ronkhi (-)
-Abdominal Examination = Bowel Sound (+) normal
-Extremities = Normal

Laboratory Monitoring
Daily Blood Test
Hematocrit 8.0 L
Trombosit 14 L
Hemoglobin 2.7 L
Leukosit 2.7 L
Eritrosit 0.82 L
ASSESMENT

ANEMIA APLASTIK
PROGRESS NOTE