Duty Report

17 February 2016
Resident on duty: dr. Shiddiq & dr. Agil
Co-ass on duty: Handelia & Vivi Silfia

Patients Recapitulation

Ms. RI, 29 yo, ITP

Mrs. SS, 54 yo, anemia, colitis infektif
Mr. R ,anemia, NHL
Mr. S, 72 yo, dyspepsia, AKI superimpose
on CKD, blood streak e.c suspect throat
irritation
Mrs., obs.dyspnea
Mrs., DHF
Mr. J, anemia, hepatoma

Patient Identity

Name:RI
Sex: Female
MR: 8155xx
Age:29 years old
Religion: Moslem
Marital status: Single
Adress: Jl. Dr Prof Satrio GG Tiong No 9 B
Date of admission : 17 February 2016

History Taking
Autoanamnesis on 17th February
2016 at 4 pm.
Chief Complaint: gum bleeding for 2
days

History of Present Illness

Patient came to the ward with chief complaint of
having gum bleeding for 2 days. Patient also
complaining about bruise on her right lower arm, right
tight, and right calf. She state that this symptoms
occur when she feels tired. Weakness and headache
since 1 day before admission. bloody stool (+).
Patient was diagnosed with ITP 6 months ago.
Patient said that since 6 months ago she has prolonged
menstrual cycle (10 days, 5 pads/day, regular cycle)
Patient consumed Metylprednisolon 3 x 32 mg for this
illness, but the dose was reduced to 3 x 4 mg 1 week
ago while having monthly check up.

History of Past Illness

ITP, no history of diabetes, hypertension,
kidney, heart, and lung diseases

Family history illness:

No family members havethe similar
symptoms
No history of diabetes, hypertension,
kidney, heart, and lung disease

Physical examination
General state : mild illness
Conciousness: Fully alert
Vital sign
Blood pressure: 110/80 mmHg
Pulse: 72 bpm, regular
Respiratory rate: 19 times/minutes
Temperature: 36,10C
Body weight: 71 kg
Body height: 161 cm
BMI: 27,39

General status
Head
Eye

: Normocephal, moon face

: pale conjunctiva (-/-), icteric sclera (-/-)

Ears : discharge (-)

Nose : septum deviation (-), discharge (-)
Mouth

: coated tongue (-), hyperemic pharynx (-),

normal T1-T1,

pale mouth mucosa (-), dried

mucosa (-), gum bleeding (+)

Neck

: JVP 5-2, lymph nodes enlargement (-)

 Thorax: symmetric, intercostals retraction (-)

COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea midclavicularis dextra
Left border

: ICS V, linea midclavicularis sinistra

Heart waist: ICS IV, linea parasternal sinistra

Auscultation : regular 1st and 2nd heart sound, murmur
(-), gallop (-)

 PULMO

Inspection : chest within normal shape, symmetric on static and dynamic state

Palpation : tactile vocal fremitus both lungs were symmetric, chest expansion
symmetric

Percussion : resonant both lungs

Auscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)

Abdomen : flat, not distended

timpani, splenomegaly(-), hepatomrgaly (-),
pain tenderness (-)
Extremities

: warm, CRT < 2 seconds, bruise lower right arm, thigh, right calf

Laboratorium
Laboratorium
test

Result
01.02.2016

17.02.2016

Hemoglobin

12,5

12,9

13-18 g/dL

Hematokrit

39

42

40 52 %

Eritrosit

5,7

6,2

4,3 6,0 juta/L

Leukosit

14790

9530

4800 10800

Trombosit

158000

9000 (DUPLO)

150000
400000

MCV

68

68

80 96 fL

MCH

22

31

27 32 pg

MCHC

32

32

32 36 g/dL

14,6

11,5-14,5 %

RDW

Normal Value

Laboratorium
test

Result
01.02.2016

Result
17.02.2016

Normal value

SGOT (AST)

16

<35 U/L

SGPT (ALT)

25

< 40 U/L

Chemical
clinique

Basofil

0-1%

eosinofil

1-3%

bands

2-6%

segment

72

56

50-70%

lymphocyte

20

35

20-40%

monocyte

2-8%

RESUME
History taking : Ms. RI, 29 years old, came to the ward with
chief complaint of having gum bleeding for 2 days. Bruise
on her right lower arm, right tight, and right calf.
Symptoms occur when she feels tired. Weakness,
headache (+) since 1 day before admission. bloody stool
(+).
Patient was diagnosed with ITP 6 months ago. Prolonged
menstrual cycle (10 days, 5 pads/day, regular cycle)
Patient consumed Metylprednisolon 3 x 32 mg for this
illness, but the dose was reduced to 3 x 4 mg 1 week ago
while having monthly check up.
Physical examination :
mouth: gum bleeding (+)
Extremity: bruise on lower right arm, thigh, right calf
Laboratory results : trombocyte 9000

List of Problems
Thrombocytopenia
DD:
Chronic liver diss
Leucemia
aplastic
Idiopathic Thrombocytopenic Purpura

Discussion
History taking: gum bleeding (+), bruise on her
lower arm, right tight, and right calf, weakness
(+), headache (+) and bloody stool (+). Patient
was diagnosed ITP 6 months ago and consumed
Metylprednisolon 3 x 32 mg, but the dose was
reduced 3 x 4 mg 1 week ago
Physical examination : gum bleeding (+), bruise
lower right arm, thigh, right calf (+)
Laboratory result : trombocyte 9000

Plan and Treatment

Plan:
Blood smear
Bone Marrow Puncture

Treatment:
Tc transfusion (premedication: dexamethasone)
Metylprednisolon 3 x 32 mg
Omeprazole 1 x 40 mg
Inpepsa 2 x 10 mg
Cavit D3 3 x 500 mg
Paracetamol 3 x 500 mg (if needed)

Prognosis
Quo ad Vitam
: dubia ad bonam
Quo ad Functionam : dubia ad bonam
Quo ad Sanationam : dubia