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ANGGIA DIAN P.S

030.08.029

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Mr .S

Name34 years oldAge

MaleSex

Rengasdengklok RT/RW 22/12 Karawang

AddressHigh schoolEducation

LabourOccupation

MoeslemReligionMarriedMarital status

July 12th 2012Admitted

SundaneseEthnic

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Fatigue since 3 daysbefore hospitalizedMain

Complaint

Dizziness

Fever

Red spots on the thighs and legs

Gum bleeding

Dark red stool

Nosebleeds

AdditionalComplaint

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Patient came to Emergency Unit of Karawang

City Hospital with complaint of fatigue since 3days before hospitalized.

He also felt dizziness , intermittent fever for 1month and red spots on the thighs and legs

since 5 days before hospitalized. Patients complain of dark red stools while in

hospital and he also complained of bleedinggums and nosebleeds. The blood that came out

a dark red,liquid and the volume is not toomuch.

Patient also say that his left leg felt pain. Hedenies any vomiting blood.

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SAME ILLNESSBEFORE (-)

HYPERTENSION

( - )DIABETES

( - )

KIDNEY DISEASE

( - )

ASTHMA

( - )

ALLERGY

( - )

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SAME DISEASE( - )

HYPERTENSION

( - ) DIABETES( - )

KIDNEYDISEASE

( - )

ASTHMA

( - ) HEART DISEASE

(-)

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Moderately ill

General appearance

Compos mentis

Consciousness

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Blood Pressure

120/90mmHg

Heart Rate

84x/mins

RespirationRate

20x/mins

Temperature

35,2 C

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NormocephaliHeadAnemic conjunctiva +/+ Icteric sclera -/-Eyes Lip: cyanosis(-)

Pharynx: hyperemic (-), symmetrical,uvula at midlineMouth

Lymph gland & Thyroid gland is notpalpable

Neck

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I : Symmetrical

Pal : Equal vocal resonance Per : Sonor in both lungs

A : Vesicular breath sound in both

lung,ronchi (-/-),wheezing (-/-)

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Inspection : Brown skin, Flat

Palpation : Sociable

No enlargement of liver and spleen

Percussion : No pain present on abdominalpercussion

Sounds dull

Auscultation :Bowel sound (+), arterial bruit (-),venous hum(-)

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Extremity Examination

Warm acrals

Oedema

Purpura

+ +

+ +

- -

- -

- -

+ +

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Blood Results Normal

Hb 7,8 12-14 g/dl

Ht 24 37-43 %

Trombocyte 39.000 150.000-450.000Leucocyte 123.800 5000-10.000

Basophyl 0 0-1%

Eosinophyl 0 1-3%Batang 0 2-6%

Segment 54 40-70%

Lymphocyte 22 20-40%

Monocyte 24 2-8%

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Anamnese

Fatigue

Dizziness

Fever

Red darkstools

Gumbleeding

Nosebleeds

Bone pain

PhysicalExamination

Anemicconjungtiva

+/+ Purpura at

the inferiorextremity

AdjuvantTest

Blood Test

Hb : 7,8 g%

Ht: 24% Leukocyte :123.800

Trombocyte:39.000

Peripheral Blood

Smear: suspectAcutemieloblasticleukimia

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Acute Myeloblastic Leukimia

Chronic Myelositic Leukimia

Chronic Limfositic Leukimia

Metaplasi myeloid

Myelofibrosis

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Acute Myeloblastic Leukimia

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Bone marrow

aspiration

Cytochemicalstaining

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IVFD NaCl

0,9% 10 dpm

PRC

Transfusion 2unit

Kalnex 3x 500

mg IV

Cefotaxim 2x1gr IV

Folic acid 3x1 Chemotherapy

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Ad sanationam :

Dubia ad Bonan

AdFungsionam :

Dubia ad

Bonam

Ad Vitam :

Dubia ad

Bonam

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