ID : Mr AM / 51 yo / driver

Chief complain : body felt weak

Recent history
since 3 days ago the patient feel the body feels weak, is felt throughout the body, continuous, increases with activity and decreases with rest, fatigue is not relieved by feeding, accompanied by blurry vision, especially when posos change from sitting to standing or activity, along with swollen and bleeding gums complaints perceived intermittent, embossed with activity and decreases with rest, bruises arising in no skin, no pain swallow, no ears, no bleeding, no chest pain, no hot body, shortness of no breath, coughs and colds as well not exist. no nausea and vomiting. urinate 6-8 times / day @ 1/2-1 cup starfruit, canary yellow, pain during urination (-). 1-2 bowel movements once a day, soft consistency, mucus blood (-), out bumps during bowel movements are not perceived Previous history : DM (-) HT (+) not routin control

Physical Examination
Common Conditions:
Moderate sick, underweight nutrition, compos mentis

Vital Sign :
BP pulse RR T WB Tall BMI : : : : : : : 150/90 mmHg 88x/mnt, reguler, isi dan tegangan cukup 26 x/menit 38,6 oC (aksiler) 50 kg 155 cm 17,6 kg/m2

THX:, normochest, chest retraction (-), pain of sternum (-) Cor: I. IC appear P. IC palpate SIC V 1 cm medial LMCS, heavy P. Configuration is not widen A. HS I-II reguler, mumur(-) gallop (-)

Eye : pale conjungtiva (+/+), sclera icteric (-)

JVP R+2cm,Limfonodi

Front side pulmo:

I. Movement of the chest simetric P. Fremitus left = right P. sonor/sonor A. Basic sound : right vesicular normal left vesicular normal complem entary : (-) Abdomen I. AW same as heigh CW, A. Peristaltic sound (+) normally Pe. Thympani, traube area thympani Liver span 8 cm, Pa. Soefel, tenderness(-) H/L not palpable Oedem (-/-) back side pulmo: I. Movement of the chest simetric P. Fremitus left = right P. sonor/sonor A. Basic sound : right vesicular normal left vesicular normal complem entary : (-)

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Laboratorium
Nilai Satuan
g/dl 106/ul % 103/ul 103/ul mg/dl mg/dl mg/dl u/l u/l mmol/l mmol/l mmol/l

Hemoglobin Eritrosit Hematokrit Lekosit Trombosit Random blood glucose Ureum Kreatinin SGOT SGPT Na K Cl

6,0 2,34 20 139,2 19 105 25 1,0 28 12 136 3,6 112

HBsAg

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Rontgen
Foto thorax PA position, hard enough, inspiration enaugh, can still distinguish soft and hard tissue, the trachea in the middle, parenkim

kiri tampak infiltrat, Cast: CTR <50%, the angle of taper

costophrenicus right and left, between the ribs is not widened, elevated diaphragm (-)

Conclusion: lung infection

ECG

Sinus Rhythm QRS rate : 84 bpm Axis : Normoaxis P Wave : normal PR interval : 0,16 s QRS duration : 0,08 ST segment : isoelectric Inversion T wave : lead II, III, aVF, V1.

LVH/RVH : -

Conclusion: Sinus ritmic, with heart rate 84 bpm, ischemic inferior

Periferal blood apperance

Eritrosit : Normokrom, normosit, anisositosis, mikrosit, sel eritroblast(-) Leukosit : increase number, sel blast(-) Trombosit : decrease, flat Conclusion : anemia normokrom normositik, leukositosis with trombositopenia suspec Leukemia

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Problem I
Hematology malignancy
Ass : ALL AML

IpDx
IpTx

:
:

DR2, PT, APTT, Reticulosit, Feces routine BMP

Partial Bedrest Diet rice 2100 Kkal, IVFD RL 20 tpm Blood transfusion PRC 1000 cc 500 cc/ a day Vit Bplex 3x1

IpMx : DR3 post transfusion, bleeding IpEx : education patient and his family about his disease and complication

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Problem II
Hipertensi stage 1
Ass IpDx IpTx : history of hipertensi (+), T 150/90 : profil lipid, funduscopi : Diet low salt < 5 gr/day captopril 3 x 25 mg : vital sign, : education patient about his disease and about his diet.

IpMx IpEx

Follow Up
06.00 S : fatigue (+) O : compos mentis, moderate sickness TV : T :100/70 RR : 20 x/menit N : 78 x/menit t : 36,5

THANK YOU

Klasifikasi Anemia Berdasarkan Morfologi dan Etiologi Anemia mikrositik hipokromik: 1. anemia defisiensi besi 2. thalasemia mayor 3. anemia sideroblastik 4. anemia akibat penyakit kronis Anemia normositik normokromik: 1. anemia pasca perdarahan akut 2. anemia aplastik 3. anemia hemolitik didapat 4. anemia akibat penyakit kronik 5. anemia pada gagal ginjal kronik 6. anemia pada sindrom mielodisplastik 7. anemia pada keganasan hematologik Anemia makrositik: 1. anemia defisiensi asam folat 2. anemia defisiensi B12 3. anemia pada penyakit hati kronik 4. anemia pada hipotiroidisme 5. anemia sindrom mielodisplastik

Kriteria Anemia WHO menetapkan cut off point anemia antuk keperluan penelitian lapangan seperti terlihat pada tabel 1. Tabel 1. Kriteria Anemi Menurut WHO Kelompok Kriteria Anemia (Hb) Laki-laki dewasa < 13g/dl Wanita dewasa tidak hamil < 12g/dl Wanita hamil < 11g/dl