ANGGIA DIAN P.S 030.08.

029

Name Age Sex Address Education

• Mr .S • 34 years old • Male • Rengasdengklok RT/RW 22/12 Karawang • High school • Labour

Occupation
Religion Marital status Admitted Ethnic

• Moeslem
• Married • July 12th 2012 • Sundanese

Main Complaint • Fatigue since 3 days before hospitalized Additional Complaint • Dizziness • Fever • Red spots on the thighs and legs • Gum bleeding • Dark red stool • Nosebleeds .

liquid and the volume is not too much. Patients complain of dark red stools while in hospital and he also complained of bleeding gums and nosebleeds. Patient also say that his left leg felt pain. intermittent fever for 1 month and red spots on the thighs and legs since 5 days before hospitalized. The blood that came out a dark red. He denies any vomiting blood. .    Patient came to Emergency Unit of Karawang City Hospital with complaint of fatigue since 3 days before hospitalized. He also felt dizziness .

HYPERTENSION SAME ILLNESS BEFORE (-) (-) DIABETES (-) KIDNEY DISEASE (-) ASTHMA (-) ALLERGY (-) .

HYPERTENSION SAME DISEASE (-) (-) DIABETES (-) ASTHMA KIDNEY DISEASE (-) (-) HEART DISEASE (-) .

Alcohol consumption (-) Smoking (+) Routine Excercise (-) Tattoos (-) Blood Transfusion (-) Injected drugs (-) Traditional beverages (-) .

General appearance • Moderately ill Consciousness • Compos mentis .

Blood Pressure •120/90mmHg Temperature •35.2 ͦ C Heart Rate •84x/mins Respiration Rate •20x/mins .

symmetrical.Head Eyes Mouth Neck • Normocephali • Anemic conjunctiva +/+ • Icteric sclera -/• Lip: cyanosis(-) • Pharynx: hyperemic (-). uvula at midline • Lymph gland & Thyroid gland is not palpable .

wheezing (-/-) .ronchi (-/-). I  Pal  Per  A : Symmetrical : Equal vocal resonance : Sonor in both lungs : Vesicular breath sound in both lung.

II absence of murmurs and gallop in heart’s sound .INSPECTION • Ictus cordis is invisible PALPATION • Ictus cordis is palpable at 5th ICS LMCS PERCUTION • Right heart border: ICS III-V LSD • Left heart border: ICS V 1cm medial LMCS • Upper heart border: ICS III LPSS AUSCULTATION • Regular I .

Flat : Sociable No enlargement of liver and spleen Percussion : No pain present on abdominal percussion Sounds dull Auscultation :Bowel sound (+).  Inspection Palpation   : Brown skin. arterial bruit (-). venous hum(-) .

Extremity Examination  Warm acrals + + + + .+ +  Oedema  Purpura ...

000 123.000-450.000 0-1% 1-3% 2-6% 40-70% Lymphocyte Monocyte 22 24 20-40% 2-8% .800 0 0 0 54 Results 37-43 % Normal 12-14 g/dl 150.Blood Hb Ht Trombocyte Leucocyte Basophyl Eosinophyl Batang Segment 7.000 5000-10.8 24 39.

.

800 • Trombocyte: 39.Anamnese Physical Examination Adjuvant Test • Blood Test • Hb : 7.8 g% • Ht: 24% • Leukocyte : 123.000 • Peripheral Blood Smear: suspect Acute mieloblastic leukimia • Fatigue • Dizziness • Fever • Red dark stools • Gum bleeding • Nosebleeds • Bone pain • Anemic conjungtiva +/+ • Purpura at the inferior extremity .

     Acute Myeloblastic Leukimia Chronic Myelositic Leukimia Chronic Limfositic Leukimia Metaplasi myeloid Myelofibrosis .

 Acute Myeloblastic Leukimia .

Bone marrow aspiration Cytochemical staining .

IVFD NaCl 0.9% 10 dpm PRC Transfusion 2 unit Kalnex 3x 500 mg IV Cefotaxim 2x 1gr IV Folic acid 3x1 Chemotherapy .

Ad Vitam : Dubia ad Bonam Ad Fungsionam : Dubia ad Bonam Ad sanationam : Dubia ad Bonan .