Mr.Ananda/24 years old/w.

25

1. Hemophilia type A + Hemarthrosis at dorso

pedis dextra
2. Epilepsi on treatment
2.1 dt intracranial bleeding
 Summary of Database

Male/24 yo/w.25
Chief complaint : leg pain
Patient suffered from pain at his right leg since one day before admission to RSSA. His leg getting
swollen and looked greenish like a contusion. It was happened spontaneously. The cause of pain
was unclear with no history of trauma. He tried to ease the pain with some ice but it was not
getting better. 10 days before it was happened to his left knee, but it was relief after given injection
of Factor VIII.
History of past illness :
In the last three years, he got factor VIII injection, the last injection was given 4 days ago at
kanjuruhan hospital
Patient was diagnosed having Hemophilia A when he was 5 years old with the first sign bruising
and bleeding according to laboratory examination at RSSA and been given anti hemophilia therapy.
When he was 14 years old, he was hospitalized for about one month because of bleeding after
circumcised and been transfused 30 units of blood.
Patient also said when he was 6 years old, he had continuous dizziness because of bleeding inside
his head. He didn’t got any surgery treatment because of high risk of bleeding. He also suffered
from seizure so he went to neurologist. Last seizure attack was 1 year ago.
History of medication :
He started to take KOATE in 2006. He took phenytoin oral 2x1 and vit B6 for the
seizure. He said he had itchy skin and small pimples over his body after taking
Tramadol. He ever had gastrointestinal bleeding after consume mefenamic acid,
got blacktarry stool and bloody vomiting

Family history :
His brother was died because of bleeding inside the head after his head hit the
wall.

Social history :
Patient works as a tire repairer. He isn’t married, doesn’t smoke nor drinking
alcohol.
 Physical examination
BP = 110/70 mmHg PR = 100 bpm, RR =20 tpm, Tax : 36.6°C

General appearance looked moderately ill, GCS456 , looked underweight

Head Pale conjunctiva -

Icterus Sclera -

Neck JVP R + 0 cmH2O 30 degree, lymphnode enlargement -

Chest Heart: Ictus invisible and palpable at ICS V MCL Sinistra

LHM ≈ ictus,
RHM: SL D
S1, S2 single, murmur (-), gallop (-)

Lung: Symetric, SF D= S v v Rh - - Wh - -
v v -- --
v v -- --

Abdomen Flat, Soefl,, bowel sound ( +) normal, liver span 8 cm, traube space tympani,
shifting dullness (-), ptechiae (+)

Extremities Oedema -/- , redness in dorso pedis dextra, pain +

 Laboratory finding
Lab Value Lab Value
Leukocyte 9400 3.500- Natrium 133 136-145 mmol / L
10.000/µL
Haemoglobine 14.80 11,0-16,5 g/dl Kalium 4.59 3,5-5,0 mmol / L

MCV 89.00 80-97

MCH 30.10 26,5-33,5 Chlorida 113 98-106 mmol / L
PCV 43,70 35-50% albumin 4.35 3.5-5.5 g/dL
Trombocyte 171000 100.000- Ureum 11.10 10-50 mg/dL
390.000/µL
Eo/Ba/Neu/Ly/M 9.9/0.4/65.4/1 0-4/0-1/51- Creatinine 0.86 0,7-1,5 mg/dL
o 9.8/4.5 67/25-33/2-5
Factor VIII 1.25 % aPTT 103,90 27.4-28.6 s
No inhibitor (prolong)
factor
CXR
 CXR
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue and bone normal,
• Trachea in the middle
• Right Hemidiaphragm and Left Hemidiaphragm were
dome shaped
• Right phrenicocostalis and Left Phrenicocostalis angle
were sharp
• Pulmo: infiltrate (-)
• Cor: site N, position N, size CTR 44 %, heart waist (+)
Conclusion : Normal CXR
 CUE AND CLUE PL IDx PDx PTx PMo

Male, 24 yo 1. -Diet HCHP 2100 ccal/day VS

Pain at his right leg Hemop -IVFD NS life line Subj
History of hilia -Transfution FFP 10 cc/kgBW Bleeding
intracranial type A -Factor VIII 2000iu 30
bleeding + cc/hour
Diagnosed Hemart
hemophilia type A hrosis
since he was 16 at
years dorso
pedis
PE dextra
BP :110/70
PR:100bpm
RR:20tpm
Tax:36.6
Prolong aPTT
Factor VIII 1,25%
no factor inhibitor
 CUE AND CLUE PL IDx PDx PTx PMo
Male, 24 yo 2. Epilepsi 2.1 intracranial EEG - phenitoin Complai
History of seizure on bleeding -Vit B6 3x2 n, VS,
History of intracranial treatment
bleeding
Had been treated with
phenytoin by
neurologist

PE:
BP :110/70
PR:100bpm
RR:20tpm
Tax:36.6
Prolong aPTT
Factor VIII 1,25%