Yuliani 030. 08.

262

Identity
Name : Ms C Age : 19 years old Gender : Female Address : Baturaden, Karawang Occupation : Student Religion : Muslim Race : Sundanese Marital Status : Single Education : Senior high school Addmision to hospital at 1st of October 2012

ANAMNESE
Autoanamnese on 2nd of October 2012 at 11.30

Prolonged menstruation since 7 days before admitted to hospital

- Fatigue - Shortness of breath - Bruises on legs


The patient came to Emergency Unit of Karawang Hospital with complaint of prolonged menstruation since 7 days before admitted to the hospital, usually patients have menstruation only 4 days. Patient feels fatigue and dizzy every menstruation. No abdominal pain. She also said raised bruises on legs when approaching menstruation, but no pain. She also complained of shortness of breath and palpitations that arise during activity and get better with rest, no wheezing and no chest pain.

3. History of present illness

She did not feel any fever nor any other complaint from any body system, normal urination. Defecation occurred intermittent, and its feces is black in color with soft consistency.

History of past illness

Family history

History of treatment
She had been hospitalized for the same symptoms and get a transfusion

Personal and Habitual history

She eats 1-2x a day, patients often eat vegetables. She rarely eats meat. She never exercises because of fatigue She does not smoke nor consume alcohol. She does not drink any herbal preparations.

Physical Examination
On 2nd of October 2012 at 11.30

General Condition

Vital Sign

Thoracal Examination - Heart

Thoracal Examination - Lung

Abdominal Examination

Extremities
Oedema Warm acrals + : : + + +

Deformation (-), brown skin, palmar erythema (-), pale (+), icteric (-). Hematom (+)

Laboratory
(1st of October 2012)
Result 3,2 gr/dL 2900 40.000 9% 0 0 0 30 65 5 Haematology Hemoglobin Leukocytes Trombocytes Hematocrite Basophil Eosinophil Neutrophil Rod Neutrophil Segment Limphocytes Monocytes Normal 12-17 gr/dL 5.000 10.000 150.000 450.000 37-43% 0-1 % 1-3 % 2-6 % 40-70 % 20-40 % 2-8 %

Result HbsAg Blood Glucose Level/ Reduction Ureum Creatinin 162 mg/ dL 10,2 mg/dL 0,74 mg/ dL

Normal 80-140 mg/dl 10-45 mg/dl 0.4-1.5 mg/dl

Laboratory
(3rd of October 2012)
Result 7,4 gr/dL 2100 23.000 22% Haematology Hemoglobin Leukocytes Trombocytes Hematocrite Normal 12-17 gr/dL 5.000 10.000 150.000 450.000 37-43%

Peripheral Blood Smear

Resume

Differential Diagnosis
Aplastic anemia MDS ITP Leukemia

Working Diagnosis
Aplastic anemia

Suggested Examination
Complete blood count Reticulocyte count Bleeding time, CT Bone Marrow Puncture

Treatments
IVFD NaCl 0,9% +Novalgin 1 amp Ceftriaxon 1x2gr Methyl prednisolon 2x125mg Sohobion 1x1amp Omeprazole 1x1 Lasix 1x1 PRC 2 kolf

Prognosis
Ad vitam : dubia ad bonam Ad sanationam : dubia ad malam Ad functionam : dubia ad malam

Thank You