ID : Mr N / 52 yo / farmer

Chief complain : body felt weak

Recent history
since one week 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 move, swallow pain no, no ears, no bleeding, no bleeding gums, bruising on the skin also does not exist, the patient also complained about perceived breathlessness since 1 week ago, shortness continuously increases with activity, decreased slightly with rest, shortness not affected by changes in emotions, weather or dust, regular patient more comfortable 2-3 cushion, and sometimes the night awakening due to crowded, swelling in the feet is not felt, no body heat, cough and colds as well not exist. no nausea and vomiting. urinate 68 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

2 month before hospitalized,with fatigue and pale, the patient had blood transfusion red is 7 colf and The patient out from hospital before doctor do BMP.
Previous history : DM (-)

HT (-), hepatitits(-) Hearth disease (-) Habitual History : housewife, smoker(-), drink free drugs(-), herbal(-)

Physical Examination
Common Conditions: Moderate sick, normoweight nutrition, compos mentis Vital Sign :

BP pulse RR T WB Tall BMI

: : : : : : :

110/70 mmHg 100x/mnt, reguler 24 x/menit 37,2 oC (aksiler) 50 kg 158 cm 20,7 kg/m2

THX:, normochest, chest retraction (-), spider naevi(-), atrofi M pectoralis mayor(-), Cor: I. IC no appear P. IC palpate SIC V 2 cm lateral LMCS, heavy P. Configuration is widen caudolateral A. HS I-II reguler, mumur pansistolic (+) grd 2/6 all chamber, referred (-), gallop (-) Front side pulmo: I. Movement of the chest simetric P. Tactile Fremitus left=right norma P. sonor/sonor normal A. Basic sound : vesiculer normsl complem entary : (-)

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

Pale(+), cianotic(-), papil tounge atrophy(-), hipertrophy ginggiva(-), bleeding gums (-),
JVP R+2cm,Limfonodi coli (-)

Back side pulmo: I. Movement of the chest simetric P. Tactile Fremitus left=right norma P. sonor/sonor normal A. Basic sound : vesiculer normsl 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 (-/-), nail flat(-)

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Laboratorium
Nilai Satuan
g/dl 106/ul %

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

2,0 0,51 2,9 15 118 18 0,7 18 18 136 3,8 105

103/ul 103/ul mg/dl mg/dl mg/dl u/l u/l mmol/l mmol/l mmol/l

HBsAg

nonreaktif

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Rontgen
Foto thorax PA position, hard enough, inspiration not enaugh, can still distinguish soft and hard tissue, the

trachea in the middle, left parenkim didnt infiltrat, the

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

Cor: CTR >50%,

Conclusion: cardiomegaly with pulmo normal

ECG

Sinus tachycardia QRS rate : 106 bpm Axis : Normoaxis P Wave : 0,04 s (normal) PR interval : 0,16 s (normal) QRS duration : 0,08 s (normal) ST segment : isoelectric Inversion T wave : -

LVH/RVH : -

Conclusion: Sinus tahikardia with HR 106 bpm

 Eritrosit : Normokrom, normosit, anisositosis,, sel

eritroblast(-) Leukosit : normal number, sel blast(-) Trombosit : decrease, Conclusion : anemia hipokrom mikrositik, with trombositopenia

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Problem I
Pansitopenia Ass : dd anemia aplastik MDS IpDx IpTx : : Reticulosit, PT, APTT, Feces routine, BMP Partial Bedrest sheet potition O2 canul 2 lpm Diet rice TKTP IVFD NaCl 0,9% 20 tpm Blood transfusion PRC 1500cc ( 500 cc/ a day )

IpMx IpEx

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

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Problem II
CHF NYHA IV LVH AHD Ass : IpDx : echocardiographi IpTx : Partial Bedrest sheet potition O2 canul 2 lpm

IpMx : vital sign IpEx : education patient about his disease.

 06.00

S : fatigue (+)
O : compos mentis, moderate sickness

TV : T :110/70 RR : 20 x/menit N : 96 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