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PHYSICIAN IN CHARGE:
flat, bowel sound normal, epigastrial tenderness (-), supple, liver span 15 cm, Traube’s
Abdomen
space tympanic
Warm, edema -/-
Extremities
-/-
LABORATORY RESULTS
Laboratory Result Normal Value Laboratory Result Normal Value
Hb 7.90 13,4 – 17,7 g/dL Natrium 140 136 – 145 mmol/L
Leucocyte 107.570 4.300-10.300/µL Kalium 4.23 3,5 – 5,0 mmol/L
Hematocrit 25.20 40 – 47 % Chloride 116 98 – 106 mmol/L
Thrombocyte 41.000 142.000-424.000/µL RBS 98 < 200 mg/dL
MCV 91.00 80 – 93 fL Ureum 24.30 16,6 – 48,5 mg/dL
MCH 28.50 27 – 31 pg Creatinine 1.24 < 1,2 mg/dL
PH 7.5 Cylinder -
Glucose - Hyaline -
Protein 1+ Granular -
Keton -
Bilirubin - 40 x
Urobilinogen - Erythrocyte 2.1
Nitrit - - Eumorfik -
Leucocyte - - Dismorfik -
Blood Trace-lysed Leukocyte 3.9
Crystal -
Bacteria 347.9
ECG
ECG INTERPRETATION
• Sinus tachycardia
• Heart Rate : 114 bpm
• Frontal axis : normal
• Horisontal axis : normal
• PR interval : 0,16 s
• QRS complex : 0,08 s
• QT interval : 0,36 s
• Conclusion : sinus tachycardia HR 114 bpm
CUE AND CLUE Problem List Initial Diagnosis Planning Planning Therapy Planning Monitoring
Diagnosis
Female / 30 yo 1.Bicytopenia + 1.1 AML Blood smear, BMP Rehidration 1L/1 hour Subj,VS
AX : ginggiva hypertrophic 1.2 MDS then maintenance with Signs of infection
Fever, Weakness, Dizziness
Fatique, Gum bleeding, and bleeding + IVFD NS 0.9% 30-40 Signs of bleeding
Metrrorhagia hepatomegaly dpm Transfusion reaction
History of blood transfusion
PE : High calory hig hprotein TRALI
GCS : 456 diet Fluid overload
BP : 90/50mmHg
PR : 128 bpm Inj. ciprofloxacine
RR : 20 tpm 2x200mg (IV)
Tax : 39.1
Hypertrophy ginggiva TC transfusion 4
hepatomegaly packs/day until PLT >
LF :
Hb : 7.90; WBC : 107.570 50.000/uL
PLT : 41.000; Ht : 25.20 PRC transfusion 2
MCV : 91.00
MCH : 28.50 packs/day until Hb ≥
Diff. count :
0.0/0.0/0.0/3.0/14.0/9.0
10 gr/dL
Metamielocyte : 1% PO:
Blast Cell : 73%
Basket cell : (+) Paracetamol 3x 500mg
SGPT : 195 Surface cooling
Blood smear : DD Chronic
myelositic leukemia, blastic crisis,
acute leukemia, myelodysplastic Plan to perform
syndrome
UL : chemotherapy when
Proteinuri : 1+ the patient is stable
Bacteriuri : 347.9
ECG : sinus tachycardia with HR
114 bpm
Risk Factor Analysis
Leukemia
1. Genetics factor
2. Chemicals
3. Environmental ( high dose of radiation, exposure to toxic
chemicals)
4. Immune system deficiencies
5. Secondary Leukemia
PROBLEM ANALYSIS
AML
LEUKOCYTOSIS
FEBRIS TROMBOSYTOPENIA
NORMOCHROMIC
NORMOCYTER ANEMIA Metrrorhagia Gum Bleeding
MANAGEMENT ANALYSIS
EMERGENCY
-
URGENCY
1. Bisitopenia (Anemia + Thrombositopenia)
> Rehydration Nacl 0,9 % 1 L/hour
> IVFD NS 0,9% 20 dpm
> TC transfusion 4 packs/day until trombocyte > 50.000/uL
> PRC transfusion 2 packs/day until Hb > 10 mg/dL
> Po B6 3x1 tablet
B12 3x1 tablet
Folic acid 1x3 tablet
> Plan for chemotherapy
CONDITION THIS MORNING
• GCS
• BP : mmHg
• PR : bpm
• RR : tpm
• Tax : 0C
• Urine production : cc/ hours
Thank You