Summary of Database

Mrs. I/ 38 y.o/ w.8

Autoanamnesis
Chief Complaint:
Bruises in hand and leg
History of Present Illness:
She came with the chief complaints is Bruises on all 4 extremities, this condition appeared for
almost 2 weeks, at first the bruises is in one are of leg, but now the bruises is become bigger than
before
She also complained general weakness for about 3 weeks, and it increased during activity. And
getting better after she took some rest or sleep. And She also felt shortness of breath since one week
before admission, the shoretness of breath increased during activity and relieved by rest
History of bleeding gums 2 weeks ago for 10 days, but these 4 days there is no gum bleeding
again. And her Menstruation history is 2 weeks ago for 10 days, changing 10 times a day, full, but now
its already stopped.
She was diagnosed with ITP since 2016 (5 years ago), but has not been under control for 8
months. The patient has just started routine for 1 week, taking medication regularly
Methylprednisolone 16mg 3x1, BC 3x1, folic acid 1x3mg, tranexamic acid 3x500mg, B complex 3x1
 Summary of Database
Past Medical History:
There is no remarkable history of any infectious disease.

Family History:
There is no history of DM, HT, autoimmune, cancer in her family. And her family
was in a healthy condition.

Social History:
She lives with his husband, and three children, and didn’t go to work.

Review of System:
• Urination was normal
• Defecation system was normal.
 Physical Examination
General appearance looked moderately ill Sat O2 98% RA
GCS 456 VAS 0/10

BP 160/100 mmHg PR 110 bpm regular strong RR 18tpm Tax 36,7 oC

Head Conjuctiva Anemic (+)

Neck JVP R+ 2 cmH20

Chest Symmetrical, retraction (-)

Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-

Sonor | Sonor Vesicular | Vesicular -
|- -|-
Sonor | Sonor Vesicular | Vesicular -
I- - |-
Cardio Ictus invisible, palpable MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Bowel Sound (+) normal, shifting dullness (-)

Liver/ unpalpable, liver span 10 cm.
Lien/ Traube space tymphany

Extremities Edema (-) , MMT 5 | 5 , Pathologic Reflex (-); Lateralisation (-), Hematome (+) all extremities
5|5
Laboratory Findings
LAB VALUE NORMAL
0,5-2,5

Leucocyte 11.950 4.700 – 11.300 /µL

Hemoglobine 5,8 11,4 - 15,1 g/dl

PCV 25 38 - 42%

Thrombocyte 11.950 142.000 – 424.000 /µL

MCV 67,5 80-93 fl

MCH 15,7 27-31 pg

Eo/Bas/Neu/ 0,6/0,2/0,0/72 0-4/0-1/51-67/

Limf/Mon ,5/16,7 25-33/2-5

Fe 23 49-151

TIBC 335 335

Sat Transferrin 7% 16-45

IPF 43,6 1,1-6,1

Ret He 12,7 28,8-32,9

Electrocardiography (24/6/2021)
 Electrocardiography (24/6/2021)

• Sinus tachycardia, HR 110 bpm

• Frontal Axis : normal
• Horizontal Axis : normal Rotation
• P wave : 0.08 sec
• PR interval : 0.12 sec
• QRS complex : 0.08 sec
• ST segment : isoelectric
• QT interval : 0.28 sec
• T wave : normal
Conclusion : Sinus rythm, with HR 110 bpm
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. ITP - - Non Pharmacology: Subjective, Vital
Mrs. ID / 34 yo / Ward 8
Subjective - Bed rest Sign, bleeding
- Soft diet 1800 kcal/day sign
- Bruising at extremity
- History of spontaneous gum Pharmacology:
bleeding 2 weeks ago - PO Methylprednisolone Education:
- Vaginal Bleeding foe 10 days 2 3x16 mg
weeks ago • Educate about
the disease
- Diagnosed ITP since 2016,
uncontrolled for 8 months • Educate about
the long term
self
Objective
Bruise on arm and leg management
• Educate to
prevent
Lab (24/6/2021): trauma
PLT: 12.000/uL
• Educate to
switch to soft
Blood Smear (24/6/2021) toothbrush
Thrombocyte: very low count

BMP RSSA (2016)

ITP
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Anemia 2.1 Chronic - Non Pharmacology: Subjective,
Mrs. ID / 34 yo / Ward 8 Hipokrom Blood Loss
Subjective - Bed rest spontaneous
Mikrositer 2.2 Anemia - Soft diet 1800 kcal/day bleeding
- General weakness since 3 weeks Deficiency Fe
ago - Tranfusion of PRC 2 pack/day
until Hb > 10 gr/dL Education
- History of spontaneous gum
bleeding 2 weeks ago • Educate
Pharmacology : about the
- Vaginal Bleeding foe 10 days 2
weeks ago - PO SF 3x200 mg disease
- Diagnosed ITP since 2016, • Educate
about the
uncontrolled for 8 months long term
Objective treatment
Conjungtiva anemis (+) • Educate to
increased
Extremity pale (+) oral intake
Lab (24/6/2021):
Hb : 5,8 gr/dL
MCV/MCH : 67,5/15,7
Fe : 23 microgram/dL
TIBC 335 microgram/dL
Saturasi Transferin 7%

Blood Smear (24/6/2021)

Eritrosit : hipokrom
anisopoikilositosis, mikrositik (+),
eliptosit (+), tear drop cell (+) cigar
cell (+)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. HT stage II 3.1 funduscopy Non Pharmacology : BP
Mrs. ID / 34 yo / Ward 8
Secondary - Bed rest
Subjective hypertensio - low sodium diet < Education:
- No history of hypertension n 2g/day • Educate
3.1.1 about the
Objective Steroid Pharmacology : disease
BP: 160/100 mmHg
induced - • Educate
3.1.2 about the
EKG: sinus rythm 110 bpm
reactive dt long term
chronic treatment
blood lost • Educate to
3.2 restrict
primary sodium
hypertensio intake
n
Problem Analysis

ITP

PLT = 12.000

Chronic blood lost

Anemia HM
Problem Analysis
KEY MESSAGE DIAGNOSIS
Management Analysis
Management Analysis
Key Message Management

ASH 2019
 Social Key Message

• Patient with ITP should be educated for the

prevention of bleeding and adherence to medication
• Good emotional support from the family, health care
provider, and spiritual support must be given to the
patient