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Morning Report Friday, 10-02-2012 Moderator: dr. Budi Darmawan, Sp.PD-KHOM Physician In Charge: IA: dr. Ella, dr.

Satria, dr.Ira IB: dr. Marthin, dr.Angga II : dr. Fajar III: dr. Shinta Sp.PD New In Patient: 1. Mr. Kharis/20 yo/w25 1. thalassemia major 2. Normochrom normocyter Anemia due to no 1 3. Heart Failure stage B 3.1 Congenital Heart Disease 3.1.1 VSD 3.2 Anemia Heart Disease 4. Growth failure due to no.1 Summary Of Database: Mr. Kharis/20 yo/w25 Chief complaint: general weakness y Patient suffered from general weakness since 3 days before admission, accompanied with headache. Patient already diagnosed with thallasemia since he was 1 year old, then he got transfusion once a month. Patient already undergone splenectom in 2007 and then he only got transfusion 0nce in 2-3 months Physical Examination: General appearance : good ; GCS 456 BP: 100/60 mmHg; PR: 88 bpm, regular; RR: 20x/mnt; Tax: 36.5C Head/neck : an (+), slightly icteric Chest : Cor : Ictus invisible & palpable at MCL ICS V sinistra LHM ~ MCL, heart waist + RHM: SL dextra S1 and S2 are single, murmur pansisitolik, blowing type, grade 2/VI, in all valve, max. in pulminal valve, radiated to ICS 3-4 Pulmo : Symmetric; no additional breath sound Abdomen : soft, normal bowel sound Liver span 14cm Lien : post splenectomy Extremity : Warm

Laboratory Findings (10/2/2012) Leukocyte Hb Hematocrite Thrombocyte MCV MCH SI TIBC Saturatin iron : 57.190/mm3 : 7.3 g/dl : 23.6 % : 570.000 : 80.4 : 25.9 : 239 : 261 : 92%

ECG (10/2/2012) Sinus rhythm with heart rate 79 bpm Frontal axis : Normal Horizontal axis : counterclockwise rotation PR interval : 0,12 QRS complex : 0,08 QT interval : 0,40 S in V1 + R in V5 > 32mm Conclusion: Sinus rhythm with heart rate 79 bpm, LVH PL IDx 1. Thalassemia 1.1 major thallasemia 1.2 thallasemia PDx PTx Hb Po.Folic acid electrop 1x3tab horesa Po. Vit B6 3x1tab Po.Vit B12 3x tb PMo Subjective Vital signs

Cue & clue /20 yo


y General weakness 3 days y Headache 3 days y Diagnosed with thallasemia y Routine transfusion y Growth failure Hb: 7.3 SI : 236 TIBC: 291 Sat Iron: 91

/20yo y Hb : 7.3 y MCV: 80.4 y MVH: 25.9

2. Normochrom normocyter anemia

2.1.due to No.1

y PRC transfusion 2 packs/day, premedication with furosemid 20mg (iv)

Subjective Vital signs Hb

/34yo 3.Heart Failure 3.1 stage B Congenital y murmur Heart pansisitolik, Disease blowing type, 3.1.1 VSD grade 2/VI, in 3.2 Anemia all valve, max. Heart disease in pulminal valve, radiated to ICS 3-4 y ECG : LVH

Ecocard y Soft diet 1900 Subjective iograph Electrolyte kcal/day y y O2 2-4lpm via nasal canule

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