MORNING REPORT

dr. Helena - IPD

Tuesday, October 16th 2014

PHYSICIAN IN CHARGE:

I A : dr. Helena, dr. Daya, dr. Bayu

I B : dr. Rizal, dr. Anshory, dr. Deddy
II : dr. Eva
III : dr. B.P. Putra, Sp.PD-KR

MODERATOR : dr. Djoko Heri, Sp.PD-KHOM

 SUMMARY OF DATA BASE
Mrs. Upik Palupi / 30 yo/Ward 25
HISTORY TAKING : autoanamnesis
CHIEF COMPLAINT : fever
HISTORY OF PRESENT ILLNESS :
Patient suffered from fever since 3 months ago. She suffered from high grade
fever, abruptly onset, and persistent. The fever did not accompanied with shivering. She did
not took any medication to relieve the fever.
She also complained of dizzines and worsening when she walked and doing hard
activity. She also felt fatique.
She complained about gum enlargement since 4 months before admission. She
also complained about weakness and headache. She complained that everytime after she
got transfusion, she felt that her gum was getting bigger. Sometimes her gum was bleeding
when she brush her teeth. Her last menstruation was a month ago and her last
menstruation was prolonged until 15 days.
There was no history of nausea and vomiting. Passing stool and passing urine
were normal.
SUMMARY OF DATA BASE
PAST MEDICAL HISTORY : She was admitted in Tulung Agung Hospital 4 x and got blood
transfusion. Then she was hospitalized in Blitar Hospital for about 6 days, before finally
reffered to RSSA.
SOCIAL HISTORY : She is a housewife, has 2 children, no smoking habit or alcohol
consumption. She consumed traditional potion everyday for a month 10 years ago.
FAMILY HISTORY : Her mother has DM and HT. Her husband passed away because of
kidney disease.
 Physical Examination
General Appearance: looked moderate ill Looked normoweight
HR :128 bpm regular
GCS: 456 BP : 90/50 mmHg RR :20 tpm Tax :39,1 °C
strong
Head Anemic conjunctiva (-) icteric sclerae (-), hypertrophy ginggiva (+)
Neck JVP: R +0 cm H2O in 30° position Lymphonode enlargement -
Wall Chest expansion symmetric

Chest Ictus invisible, palpable ICS V MCL S Trill: - Heaves: -

Heart RHM ~ SL D LHM ~ ictus
S1 and S2 single, no murmur

Stem Fremitus D=S SS v v Rh - - Wh - -

Lung SS vv - - - -
SS vv - - - -

flat, bowel sound normal, epigastrial tenderness (-), supple, liver span 15 cm, Traube’s
Abdomen
space tympanic
Warm, edema -/-
Extremities
-/-
 LABORATORY RESULTS
Laboratory Result Normal Value Laboratory Result Normal Value
Hb 7.90 13,4 – 17,7 g/dL Natrium 140 136 – 145 mmol/L
Leucocyte 107.570 4.300-10.300/µL Kalium 4.23 3,5 – 5,0 mmol/L
Hematocrit 25.20 40 – 47 % Chloride 116 98 – 106 mmol/L
Thrombocyte 41.000 142.000-424.000/µL RBS 98 < 200 mg/dL
MCV 91.00 80 – 93 fL Ureum 24.30 16,6 – 48,5 mg/dL
MCH 28.50 27 – 31 pg Creatinine 1.24 < 1,2 mg/dL

MCHC 31.30 32 – 36 g/dL Albumin 3,5 – 5,5 g/dL

Differential count 0.0/0.0/0.0/3.0/1 0-4/0-1/51-67/25- Blood smear
4.0/9.0 33/2-5 % Erythrocyte Normochrome
Others Metamielosit=1% Anisositosis
, Blast cell=73%, Increase
Basket Cell : + Vacuolisasi Netrofil (+)
Decrease
Giant Thrombocyte (+)
SGOT 42 0-40 U/L
SGPT 195 0-41 U/L
 URINALYSIS

Lab Value Lab Value

Urinalysis Yellow, clear 10 x
SG 1.010 Epithelial 3.0

PH 7.5 Cylinder -

Glucose - Hyaline -

Protein 1+ Granular -

Keton -

Bilirubin - 40 x
Urobilinogen - Erythrocyte 2.1

Nitrit - - Eumorfik -
Leucocyte - - Dismorfik -
Blood Trace-lysed Leukocyte 3.9
Crystal -
Bacteria 347.9
ECG
 ECG INTERPRETATION
• Sinus tachycardia
• Heart Rate : 114 bpm
• Frontal axis : normal
• Horisontal axis : normal
• PR interval : 0,16 s
• QRS complex : 0,08 s
• QT interval : 0,36 s
• Conclusion : sinus tachycardia HR 114 bpm
 CUE AND CLUE Problem List Initial Diagnosis Planning Planning Therapy Planning Monitoring
Diagnosis
Female / 30 yo 1.Bicytopenia + 1.1 AML Blood smear, BMP Rehidration 1L/1 hour Subj,VS
AX : ginggiva hypertrophic 1.2 MDS then maintenance with Signs of infection
Fever, Weakness, Dizziness
Fatique, Gum bleeding, and bleeding + IVFD NS 0.9% 30-40 Signs of bleeding
Metrrorhagia hepatomegaly dpm Transfusion reaction
History of blood transfusion
PE : High calory hig hprotein TRALI
GCS : 456 diet Fluid overload
BP : 90/50mmHg
PR : 128 bpm Inj. ciprofloxacine
RR : 20 tpm 2x200mg (IV)
Tax : 39.1
Hypertrophy ginggiva TC transfusion 4
hepatomegaly packs/day until PLT >
LF :
Hb : 7.90; WBC : 107.570 50.000/uL
PLT : 41.000; Ht : 25.20 PRC transfusion 2
MCV : 91.00
MCH : 28.50 packs/day until Hb ≥
Diff. count :
0.0/0.0/0.0/3.0/14.0/9.0
10 gr/dL
Metamielocyte : 1% PO:
Blast Cell : 73%
Basket cell : (+) Paracetamol 3x 500mg
SGPT : 195 Surface cooling
Blood smear : DD Chronic
myelositic leukemia, blastic crisis,
acute leukemia, myelodysplastic Plan to perform
syndrome
UL : chemotherapy when
Proteinuri : 1+ the patient is stable
Bacteriuri : 347.9
ECG : sinus tachycardia with HR
114 bpm
Risk Factor Analysis
Leukemia
1. Genetics factor
2. Chemicals
3. Environmental ( high dose of radiation, exposure to toxic
chemicals)
4. Immune system deficiencies
5. Secondary Leukemia
PROBLEM ANALYSIS
AML

LEUKOCYTOSIS

FEBRIS TROMBOSYTOPENIA

NORMOCHROMIC
NORMOCYTER ANEMIA Metrrorhagia Gum Bleeding
MANAGEMENT ANALYSIS
EMERGENCY
-
URGENCY
1. Bisitopenia (Anemia + Thrombositopenia)
> Rehydration Nacl 0,9 % 1 L/hour
> IVFD NS 0,9% 20 dpm
> TC transfusion 4 packs/day until trombocyte > 50.000/uL
> PRC transfusion 2 packs/day until Hb > 10 mg/dL
> Po B6 3x1 tablet
B12 3x1 tablet
Folic acid 1x3 tablet
> Plan for chemotherapy
 CONDITION THIS MORNING

• GCS
• BP : mmHg
• PR : bpm
• RR : tpm
• Tax : 0C
• Urine production : cc/ hours
Thank You