YulianiYuliani

030. 08. 262030. 08. 262

Name : Ms C Age : 19 years old Gender : Female Address : Baturaden, Karawang Occupation : Student Religion : Muslim Race : Sundanese Marital Status : Single Education : Senior high school Addmision to hospital at 1st of October 2012

Identity

ANAMNESE

Autoanamnese on 2nd of October 2012 at 11.30

Prolonged menstruation since 7 days before admitted to hospital

- Fatigue- Shortness of breath - Bruises on legs

The patient came to Emergency Unit of Karawang Hospital with complaint of prolonged menstruation since 7 days before admitted to the hospital, usually patients have menstruation only 4 days. Patient feels fatigue and dizzy every menstruation. No abdominal pain. She also said raised bruises on legs when approaching menstruation, but no pain.

She also complained of shortness of breath and palpitations that arise during activity and get better with rest, no wheezing and no chest pain.

She did not feel any

fever nor any other complaint from any body system, normal urination. Defecation occurred intermittent, and its feces is black in color with soft consistency.

3. History of present illness

History of past illness

Family history

History of treatment

She had been hospitalized for the same symptoms and get a transfusion

Personal and Habitual history

She eats 1-2x a day, patients often eat vegetables.

She rarely eats meat. She never exercises because of fatigue She does not smoke nor consume alcohol. She does not drink any herbal preparations.

Physical Examination

On 2nd of October 2012 at 11.30

General Condition

Vital Sign

Thoracal Examination - Heart

Thoracal Examination - Lung

Abdominal Examination

Oedema : - -

- -

Warm acrals : + + + +

Deformation (-), brown skin, palmar erythema (-), pale (+), icteric (-). Hematom (+)

Extremities

Haematology Result Normal

Hemoglobin 3,2 gr/dL 12-17 gr/dL

Leukocytes 2900 5.000 – 10.000

Trombocytes 40.000 150.000 – 450.000

Hematocrite 9% 37-43%

Basophil 0 0-1 %

Eosinophil 0 1-3 %

Neutrophil – Rod 0 2-6 %

Neutrophil – Segment

30 40-70 %

Limphocytes 65 20-40 %

Monocytes 5 2-8 %

Laboratory (1st of October 2012)

Result Normal

HbsAg - -

Blood Glucose Level/ Reduction

162 mg/ dL 80-140 mg/dl

Ureum 10,2 mg/dL 10-45 mg/dl

Creatinin 0,74 mg/ dL 0.4-1.5 mg/dl

Haematology Result Normal

Hemoglobin 7,4 gr/dL 12-17 gr/dL

Leukocytes 2100 5.000 – 10.000

Trombocytes 23.000 150.000 – 450.000

Hematocrite 22% 37-43%

Laboratory (3rd of October 2012)

Peripheral Blood Smear

Resume

Aplastic anemia MDS ITP Leukemia

Differential Diagnosis

Working Diagnosis

Aplastic anemia

Complete blood count Reticulocyte count Bleeding time, CT Bone Marrow Puncture

Suggested Examination

IVFD NaCl 0,9% +Novalgin 1 amp Ceftriaxon 1x2gr Methyl prednisolon 2x125mg Sohobion 1x1amp Omeprazole 1x1 Lasix 1x1 PRC 2 kolf

Treatments

Ad vitam : dubia ad bonam Ad sanationam : dubia ad malam Ad functionam : dubia ad malam

Prognosis

Thank You