MORNING REPORT

C3
A 58 year-old female was admitted to R.D.
Kandou Hospital at C3 ward on sunday 4th
March 2018 at 19.00
With main complaint: Nauseous
 Patient’s identity
Name : Mrs VS
Age : 58 yrs
Sex : female
Occupation : housewife
Education : Junior High School
Ethnicity :-
Religion : Christian
 Present Medical History
• Patient feels nauseous, and epigastric pain since 3 days b.a.
• Vomiting 1 time 1 days b.a. Contains food and no blood.
• No fever. No shortness of breath.
• General weakness since yesterday. Loss of apetite (+)
• Urinating and defecating had no complain
• Patient already admitted to hospital on Sept 2017
• Patient was diagnosed with Chronic Myeloid Leukemia
 Past Medical History
• CML -> Taking Tasigna until now
• History of previous heart, liver, DM, kidney, lung, Uric
acid, cholesterol was denied.
History of allergy :
Unknown
History of immunization :
Unknown

Habit history :
Alkoholism (-)
Smoking (-)
Worked at garden and using pestiside
 Family History
• None experienced the same illness
General anamnesis ( review of system )
General : General weakness
Skin :-
Head and neck :
Eye : Conj Anemic (+/+)
Ear :-
Nose :
Mouth and throat: -
Respiratory : -
Chest :-
Heart :-
Abdomen :
Genitalia :-
Kidney :-
Hematology :-
Endocrine :-
Musculosceletal : -
 Physical Examination
• GC: Moderate ill Sens : CM
• C3:BP: 110/70mmHg, PR 80x/m, RR 18/m, T 36,5ºC SpO2 98%
• ER :BP: 110/80mmHg ,PR 78x/m, RR 20x/m, T 36,7 C SpO2 97%
• BW 45 kg, BH 150 cm, BMI 21 kg/m2
• Head : conj. anemic (+), scl. icteric(-) Gingiva hipertrophy (-)
• Neck : JVP not distended, lymph nodes enlargement (-), thyroid (-)
• Thorax :
• Heart :
– Insp : IC not visible
– Palp : IC not palpable,
– Perc : left border: ICS V 1cm lateral midclavicullar line
right border: ICS IV parasternal line
– Ausc : SI-II regular, murmur (-), gallop (-)
 Physical examination
• Lung : Insp : Symmetric
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular, ronchi -/-, wheezing -/-
• Abd :
Insp : Flat, symmetric
Palp : Tender,
Liver and spleen not enlarged
Perc : Tympanic in all regions
Ausc : Bowel sound (+) normal
• Extr : warm, edema (-/-)
• Petechie (-)
 Lab Result
4/03/2018
• Leucocyte 1000 • RBS 109
• RBC 2.7 • Ureum 9
• Hb 2.5 • Creatinin 0.7
• Ht 24.4% • Natrium 140
• Platelet 11.000
• MCH 30
• Kalium 3,3
• MCHC 34 • Chloride 107
• MCV 87 • SGOT 24
• SGPT 30
PT 15 (12-16)
INR 1,3 (1.32)
ApTT 24.4(27-39)
ECG 4-3-18
 ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus Sinus Rhythm
Speed / HR (times/mnt) 96x/min 1500/R-R’
Axis Normal Normal / RAD / LAD
Morphology P wave 0,12 sec Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0,20 sec 0,12” – 0,20”
QRS complex duration 0,08 sec 0,05” – 0,11”``
ST segmen Normal Normal / Elevated / Depressed
T wave normal Normal / abnormal
QT Interval 0,40 sec cQT = QT interval / vR-R’ Interval
U wave Absent Appear / not appear
CONCLUSION : Sinus rhythm, HR 96x/m
 Rontgen components Interpretation
Identity Same
KV normal
Symmetric Symmetric
Diaphragma Normal
Mediastinum Normal
Sinus Costophrenicus SHarp
Sinus Cardiophrenicus Sharp
Bone Intact
Cor + CTR 13/22 x 100% = 59%
Pulmo Parenchym Infiltrate (-)
CONCLUTION : Cardiomegaly
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring

1 General Weakness CBC, Diff Count o

IVFD NS 0,9% •Educate the •Observation for
family about the vital signs.
Head: conj. anemic (+) Blood smear Consult to condition of the
Abdomen : Hematology patient and plans
Hepatosplenomegaly
(+) BMP division ahead.

History of CML (+)

History of taking
Tasigna for 2months

BCR-ABL detected
 Chronic Myeloid
Leukemia
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring

2 General weakness BMP o

Transfusion PRC •Educate the Observation for
Until Hb>9mg/dL family about the bleeding sign
PE : Conj. anemic (+) DL control condition of the
TC transfusion patient and plans
Lab : Blood Smear until PLT >50.000 ahead.
Hb 2.5
Leuko 1000 Stop Tasigna
Thrombocyte 11.000

-> Pansitopenia ec
Drug Induced
No Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring

1 Vomiting (+) - Rantidine •Educate the •Observation for

1 time a 2x50mg/IV family about vital signs.
Nauseous (+), the condition
no diarrhea of the patient
Domperidon and plans
Anemic(+) 3x10mg/PO ahead.
Blood (-)
Swallowing
difficulty (-)
Age > 40th

Dypepsia
syndrome
 Conclusion
Has been reported A 58 year-old woman admitted
to R.D. Kandou Hospital at C3 ward on March 4th,
2018 at 19.00 with main complain Nauseous,
from anamnesis, physical examination and
laboratory diagnosed with CML and dyspepsia
 Prognosis
• Ad Vitam : Dubia ad malam
• Ad Functionam : Dubia ad malam
• Ad Sanationam : Dubia ad malam
Thank You
Anemia normositik normokrom
 Algoritme Diagnosis Anemia Makrositik
Anemia
MCV > 100fl & MCHC > 30g/dl

Indeks retikulosit < 10% Indeks retikulosit 10-15% Indeks retikulosit > 15%

Kadar B12 & Folat Perdarahan/Hemolisis

Definisi Folat Defisiensi B 12 Normal TIDAK YA

Analisa gizi Schilling test BMP

Baik Kurang Terkoreksi Tidak Megaloblastik Non Megaloblastik

Terkoreksi
Def. Intrinsik Hipoplastik
Malabsorpsi
Malabsorpsi Mieloplastik
Inapropriate diet
Cincin sideroblastik Kongenita/Obat
 Algoritme Diagnosis Anemia Mikrositik Hipokrom

Anemia
MCV < 80fl & MCHC < 30g/dl

Indeks retikulosit < 10% Indeks retikulosit 10-15% Indeks retikulosit > 15%

SI / IBC, Transferin, Feritin Elektroforesis hemoglobin

Normal/Tinggi Definisi Fe Normal Abnormal

BMP Pasokan, Absorpsi ? Dalam terapi Fe ? Hemoglobinopati

Gangguan metabolisme Fe Hemolitik ? Thalasemia

Mielodisplasia
ACD
Algoritme Diagnosis Anemia Normositik Normokrom
Anemia
MCV 80-100fl & MCHC > 30g/dl

Indeks retikulosit < 10% Indeks retikulosit 10-15% Indeks retikulosit > 15%

Abnormal hambatan Kehilangan/Penghancuran Berlebihan

Produksi/Pematangan BMP
Periksa: Bilirubin Indirek, LDH
Normal Tinggi
Normal
Anemia hemolitik/def. Fe dlm terapi Perdarahan ?
Periksa ACTH Anemia hemotolik
Tidak Ya
Infiltrasi Keganasan Periksa Urin

Hipoplasia SSTL
Tes coombs, C3/C4 Negatif Positif Hb/
Cincin sideroblastik ? Anti DsDNA hemosiderin

Positif Hemolisis Hemolisis

AIHA Primer or Secunder Ekstravaskuler Intravaskuler

Negatif Detect Intra corpuscular

Detect Intra corpuscular Mekanin, Toksin, Infeksi