SCENARIO

Ms. CT, 18 years old, 54 kg, checked herself in the hospital because she felt that she was bleeding frequently, had

worsened for the last 3 days with bleeding gums and nosebleeds, black stools. The patient has felt red spots all over

the body starting 1 year ago, various sizes disappear in one week. The patient after a traffic accident 1 week ago,

bruises, hematoma on the cheek and right eye. The patient was diagnosed with ITP.

BMA (bone marrow aspiration) examination:

• Megakaryocytes can be increased or normal & agranular / do not contain platelets

Peripheral Blood smear examination:

• Hypochromic anemia and leukocytosis with thrombocytopenia

• HB (Hemoglobin) is a metalloprotein in red blood cells that functions as a carrier of oxygen from the lungs
throughout the body, in mammals and other animals. Hemoglobin is also a carrier of carbon dioxide back to the
lungs to be exhaled out of the body.
• Hematoma is an abnormal accumulation of blood outside the blood vessels. This condition occurs due to damage
to blood vessels which causes blood to leak into other body tissues.
• MCHC (mean corpuscular hemoglobin concentration) is a calculation of how dense the hemoglobin molecule is in
red blood cells.
• Thrombocytes are non-core cells from blood that play a role in the clotting process. These cells work by
freezing themselves to stop bleeding
• Hypochromic Anemia: Anemia characterized by a disproportionate decrease in red blood cell hemoglobin and an
increase in the pale area in the middle of the red blood cells.
• ALT is an enzyme that is used as an indicator of liver damage. ALT functions to catalyze the transfer of amino
acids from alanine to α-ketoglutarate.
1. What is the appropriate pharmacological and
non-pharmacological therapy for the
patient?
2. How to monitor and evaluate patients?

3. Etiology of the patient's disease ?

4. What is the pathophysiology of the disease in

the scenario?
1. Pharmacological therapy that can be given to patients affected by ITP
(Idiopathic Thrombocytopenic Purpura), is oral corticosteroids which are the
main therapy for the treatment of ITP, IVIG immunoglobulin and anti-D for
cases with positive rhesus D. Meanwhile, for non-pharmacological therapy,
reduce/limit physical activity, avoid using preparations that can interfere
with platelets, eat nutritious foods, starting with soft foods.
2. Monitoring and evaluation of patients :
• Monitor patients who have a risk of bleeding
• Monitor signs and symptoms of bleeding
• Monitor orthostatic vital signs, including blood pressure
• Monitor blood clotting including prothrombin time (PT), partial
thromboplastin time (PTT). fibrinogen, decreased fibrin and platelet count if
needed•
• Protect the patient from trauma that can cause bleeding
• Teach patient and/or family about signs of bleeding and appropriate action.
• Tell the patient to avoid invasive procedures
3. Etiology: Blood clotting disorder or what is known as coagulation,
usually occurs after an injury or injury causes bleeding. With blood
clotting, the body will not lose too much blood. Blood clotting disorders
can occur if one of the two components is abnormal. As a result, you may
experience heavy bleeding due to blood that is difficult to clot or actually
experience blood clots because blood clots too easily.
4. Pathophysiology of immune thrombocytopenic purpura or ITP is
thought to be due to abnormalities in platelet activity. This is also
sometimes associated with an autoimmune role which then directly
affects platelets.
In analyzing a problem, there are several things that need to be
considered, namely the pathophysiology of the disease diagnosed by
the patient based on the state of the symptoms and the patient's
accompanying history, then matching the symptoms experienced by
the patient with the general symptoms that appear as a form of
clinical manifestation of the disease, interpretation of clinical data
as a diagnosis enforcer and as a reference for the application of
therapy both in terms of pharmacology and non-pharmacology.
1. To find out the pathophysiology of the disease in the
scenario.
2. To find out the etiology of the disease in the scenario.
3. To know the monitoring and evaluation of the scenario.
4. To find out pharmacological and non-pharmacological
therapy in the scenario
 Pathophysiology
ITP is an autoimmune disease caused by the destruction of normal platelets due to the presence of antibodies
(antibody-mediated destruction of platelets) and impaired production of megakaryocytes. ITP disease is a
disorder due to immune dysregulation with the end result being a loss of tolerance of the immune system
against self-antigens that are on the surface of platelets and megakaryocytes. T cells are activated due to the
recognition of platelet-specific antigen on APC (antigen presenting cell) which then induces antigen-specific
expansion in B cells. Then B cells produce autoantibodies that are specific for glycoproteins which are
expressed on platelets and megakaryocytes. Circulating platelets are bound by platelet autoantibodies and
then attach to splenic macrophage FC receptors resulting in platelet destruction. In addition, anti-
megakaryocyte autoantibodies are also formed which reduce the ability of megakaryocytes to produce
platelets. Autoantibody production occurs which increases platelet destruction by splenic macrophages and
decreases platelet production due to anti-megakaryocyte antibodies (Sari, 2018).
 Etiology
Immune thrombocytopenic purpura can occur with infections ( human immunodeficiency virus),
malignancies (adenocarcinoma and lymphoma), and generalized variable immunodeficiency and
autoimmune diseases (systemic lupus erythematosus, autoimmune hepatitis, and thyroid
disease).[3] Somehow in this disease, there is the formation of anti-platelet antibodies that lead to
the destruction of platelets. Medications can also cause autoimmune thrombocytopenia, such as
acetazolamide, aspirin, aminosalicylic acid, carbamazepine, cephalothins, digitoxin, phenytoin,
meprobamate, methyldopa, quinidine, rifampin, and sulfamethazine. (NCBI, 2022).
 Risk factor
According to (PPNI, 2016) the risk factors for bleeding are:
a. Aneurysm (widening of blood vessels)
b. Gastrointestinal disorders (eg stomach ulcers, polyps, varicose veins)
c. Impaired liver function (eg cirrhosis of hepatitis)
d. Pregnancy complications (eg premature rupture of membranes, placenta previa/abruption,
multiple pregnancies)
e. Post partum complications (uterine antonym, retained placenta)
f. Coagulation disorders (eg thrombocytopenia)
g. Effect of pharmacological agents
h. Surgical action
i. Trauma
j. Lack of exposure to information about bleeding prevention
k. process of violence
 Non-pharmacological therapy
Diet: should be given nutritious food with high protein, especially those from animal protein.
. Vitamin C: Vitamin C is given 3 x 100 mg/day to increase iron absorption. Blood transfusion:
Iron deficiency anemia rarely requires blood transfusions. Indications for blood transfusion in
iron deficiency anemia are:
- Presence of anemic heart disease with the threat of heart failure.
- Very symptomatic anemia, for example anemia with very prominent symptoms of dizziness.
- Patients need a rapid increase in hemoglobin levels such as in the last trimester of pregnancy or
preoperatively
(Iron deficiency anemia, 2017)
 Education
General practitioners can assess bleeding and make
recommendations about management, as well as referrals to
specialists (hematologists). Adults must remain compliant
with medication (NCBI, 2022).
 subjective
Ms. CT, 18 years 54 kg checked herself at the hospital
because she felt that there was frequent bleeding, was
heavy for the last 3 days with bleeding gums and
nosebleeds, black bowel movements. Red spots appeared all
over the body felt by the patient starting 1 year ago,
various sizes disappeared in one week. The patient after a
traffic accident 1 week ago, bruises, hematoma on the cheek
and right eye
 objective
BMA (bone marrow aspiration) examination:
- Megakaryocytes can be increased or normal &
agranular / do not contain platelets Peripheral blood
smear examination:
- Hypochromic anemia and leukocytosis with
thrombocytopenia
 Assessment
Based on the scenario, it is known that several examinations were carried out on the patient, the first was the
examination of Bone Marrow Aspiration (BMA), and found the presence of megakaryocytes that could be
elevated/in normal levels and agranular/not containing platelets. BMA is a procedure to collect and examine
the bone marrow of the spongy tissue inside some of the larger bones. This procedure can show whether the
bone marrow is healthy and producing a normal number of blood cells. Platelets are formed and released into
the bloodstream by precursor cells called megakaryocytes (MK). The production of platelets by
megakaryocytes requires a complex series of remodeling events that result in the release of thousands of
platelets from a single megakaryocyte. Abnormalities in this process can lead to disorders, one of which is ITP
(Tejinder Singh Bhasin et al., 2013). As for examination of peripheral blood smears, known hypochromic anemia
and leukocytosis with thrombocytopenia. Peripheral blood smear showed normochromic normocytic erythrocyte
morphology, normal leukocyte count with atypical lymphocytes, and low platelet count with normal morphology
(Sari, 2018).
 Assessment
The use of fluid therapy where fluid therapy is one of the therapies that will determine the success
of handling critically ill patients. In resuscitation steps, step D (“drug and fluid treatment”) in
advanced life support, is an important step that is carried out simultaneously with other steps. This
action is often a "life saving" step in patients who suffer from large fluid losses such as
dehydration due to vomiting, diarrhea and shock.
• Corticosteroids
serves to suppress the immune system and platelet count. The doctor will give instructions to the
patient to stop taking this drug if the platelet count has returned to normal
• Eltrombopag
This type of drug is used to help the bone marrow to produce more platelets.
• Rituximab
serves to relieve the immune system response that causes the destruction
of platelets.
• Intravenous immunoglobulin (IVIg)
is a drug that is given to increase the platelet count when other drugs are no
longer effective in treating ITP. This drug is also used to increase the blood
count when a patient is bleeding before undergoing surgery.
 Plan
- Diet TKTP 2100
- KSR 3 X 1
- CaCo 2 TB 3 X 1
- P2 14 tpm
- Methylprednisolone 3 x 16 mg
 CONCLUSION
The patient is diagnosed with ITP (Idiopathic thrombocytopenic purpura) because the exact cause is
not known, but with the development of science, it turns out that the cause of ITP itself is the immune
system. The symptoms of this ITP are bleeding of the gums and a history of bleeding, this is in
accordance with the symptoms felt by the patient. After being analyzed, it turned out that there was
a correlation between my previous history of events, namely the patient had a traffic accident 1 week
ago. When he checked himself at the hospital, the symptoms he experienced were more frequent,
namely bleeding and getting worse in the last 3 days with bleeding gums and black or melena
chapters.
 One of the symptoms that needs to be underlined is melena, which can be a sign of
bleeding in the digestive organs. In addition, it is also necessary to pay more attention to
the history of the disease or previous symptoms, namely the appearance of red spots all
over the body felt by the patient starting 1 year ago. This could have occurred due to the
patient's history of abnormal coagulation which occurred not only as a result of injury, but
can also cause secondary injury. Furthermore, rational pharmacological therapy for
patients is TKTP diet 2100, KSR 3x1, Caco2 TB 3x1, P2 14tpm and methylprednisolone
3x10 mg.
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