1

Misnizar/female/46yo/FW 20

Chief Complaint:
Fatigue and weakness since 3 days ago

• Fatigue and weakness since one week ago

Present Illness History

• Fatigue and weakness since 3 days ago

• Looking pale sice 1 week ago
• There is no fever, cough and breathlessnes
• There is no nausea and vomit
• There is no decrease appetite
• Defecation and mixturition normal
• There is no epistaxis and gum bleeding
Past illness history

• There is no history of hypertension

• There is no history of DM
• There is no history of heart disease

Family illness history

• There is no family member have same

disease
Physical Examination
VII

• General Appearance : moderate

• Consciousness level: CMC

• BP : 118/64 mmHg

• HR : 72 x/minute

• RR : 20 x/minute

• T : 36,6 º C

• SaO2 : 97%
• Eye VII
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and spleen is not palpable, epigastric pain (+)
– Percussion: tympani,
– Auscultation: bowel sound (+) increase
– CVA : flank pain (-/-)

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 7,0 gr/dl
Ht 21 %
WBC 8.890 /mm3
Platelet 19.000/mm3
Diff. Count 0/0/31/65/4
Pathologyc cell Eritrosit berinti
Albumin/globulin 3,9/4,0
Bilirubin direk/indirek 0,4/0,6
Sgot/sgpt 52/21
Ureum/kreatinin 28/0,8
Na/K/Cl 139/3,7/109
PT/APTT 12,0/28,4
Chest X-Ray VII
ECG VII
Problems
• Anemia
• Trombositopenia
Working Diagnosis

• Bisitopenia cb aplasia
• Trombositopenia cb suspect ITP
• Moderate anemia normocitic normocrom cb chronic disease
Therapy

• Rest / diet high calory high protein

• IVFD NaCl 0,9% 8 h/kolf
• Vitamin B complex 1 x 1 tab PO
Plan

• Urinalisa
• Benzidine test
• Crossmatch PRC 2 unit, transfusion PRC 2 unit
• Crossmatch TC 5 unit, transfusion TC 5 unit