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Duty Report
17 February 2016Resident on duty: dr. Shiddiq & dr. Agil
o!ass on duty: "andelia & #i$i Sil%a
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atients Re'apitulation
• (s. R)* 2+ y,o* )-
• (rs. SS* / y,o* aneia* 'olitis ineti
• (r. R *aneia* 3"4
• (r. S* 72 y,o* dyspepsia* A5) superiposeon 5D* blood strea e.' suspe't throatirritation
• (rs.* obs.dyspnea• (rs.* D"F
• (r. * aneia* hepatoa
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atient )dentity
• 3ae:R)
• Se: Feale
• (R: 81
• Age:2+ years old
• Religion: (osle
• (arital status: Single
• Adress: l. Dr ro Satrio 99 -iong 3o +
• Date o adission : 17 February 2016
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"istory -aing
• Autoananesis on 17th February2016 at / p.
• hie oplaint: gu bleeding or 2days
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"istory o resent )llness
atient 'ae to the ;ard ;ith 'hie 'oplaint oha$ing gu bleeding or 2 days. atient also'oplaining about bruise on her right lo;er ar* righttight* and right 'al. She state that this syptos
o''ur ;hen she eels tired. ?.
atient ;as diagnosed ;ith )- 6 onths ago.
atient said that sin'e 6 onths ago she has prolongedenstrual 'y'le =10 days* pads@day* regular 'y'le?
atient 'onsued (etylprednisolon 2 g or thisillness* but the dose ;as redu'ed to / g 1 ;eeago ;hile ha$ing onthly 'he' up.
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"istory o ast )llness
)-* no history o diabetes* hypertension*idney* heart* and lung diseases
• Faily history illness:
3o aily ebers ha$ethe siilarsyptos
3o history o diabetes* hypertension*idney* heart* and lung disease
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hysi'al eaination
• 9eneral state : ild illness
• on'iousness: Fully alert
• #ital sign
– lood pressure: 110@80 "g
– ulse: 72 bp* regular
– Respiratory rate: 1+ ties@inutes
– -eperature: 6*10
– ody ;eight: 71 g
– ody height: 161 '
– (): 27*+
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9eneral status
•"ead : 3oro'ephal* oon a'e
Bye : pale 'onCun'ti$a =!@!?* i'teri' s'lera =!@!?
Bars : dis'harge =!?
3ose : septu de$iation =!?* dis'harge =!?
(outh : 'oated tongue =!?* hyperei' pharyn =!?*
noral -1!-1* pale outh u'osa =!?* dried
u'osa =!?* gu bleeding =>?
•3e' : # !2* lyph nodes enlargeent =!?
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• -hora: syetri'* inter'ostals retra'tion =!?
R
)nspe'tion: )'tus 'ordis =!?
alpation: hea$e =!?* lit =!?* thrill =!? er'ussion:
Right border: )S #* linea id'la$i'ularis detra
4et border : )S #* linea id'la$i'ularis sinistra
"eart ;aist: )S )#* linea parasternal sinistra
Aus'ultation : regular 1st and 2nd heart sound* urur
=!?* gallop =!?
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–E4(
• )nspe'tion : 'hest ;ithin noral shape* syetri' on stati' and dynai' state
• alpation : ta'tile $o'al reitus both lungs ;ere syetri'* 'hest epansion
syetri'
• er'ussion : resonant both lungs
• Aus'ultation : $esi'ular breathing sounds* rales =!@!?* ;heeing =!@!?
• Abdoen : Gat* not distended
tipani* splenoegaly=!?* hepatorgaly =!?*
pain tenderness =!?• Btreities : ;ar* R- H 2 se'onds* bruise lo;er right ar* thigh* right 'al
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4aboratoriu
4aboratoriutest
Result Normal Value
01.02.2016 17.02.2016
"eoglobin 12* 12*+ 1!18 g@d4
"eatorit + /2 /0 I 2 JBritrosit *7 6*2 /* I 6*0 Cuta@4
4euosit 1/7+0 +0 /800 I 10800
-robosit 18000 +000 =DE4? 10000 I/00000
(# 68 68 80 I +6 4(" 22 1 27 I 2 pg
(" 2 2 2 I 6 g@d4
RD< 1/*6 11*!1/* J
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Laboratoriumtest
Result01.02.2016
Result17.02.2016
Normal value
Chemicalclinique
S9- =AS-? 16 H E@4
S9- =A4-? 2 H /0 E@4
aso%l 0 0 0!1J
eosino%l 0 0 1!J
bands 2!6J
segent 72 6 0!70J
lypho'yte 20 20!/0J
ono'yte 6 2!8J
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RBSE(B
"istory taing : (s. R)* 2+ years old* 'ae to the ;ard ;ith'hie 'oplaint o ha$ing gu bleeding or 2 days. ruiseon her right lo;er ar* right tight* and right 'al.Syptos o''ur ;hen she eels tired. ?.
atient ;as diagnosed ;ith )- 6 onths ago. rolongedenstrual 'y'le =10 days* pads@day* regular 'y'le?
atient 'onsued (etylprednisolon 2 g or thisillness* but the dose ;as redu'ed to / g 1 ;ee ago;hile ha$ing onthly 'he' up.
hysi'al eaination :
outh: gu bleeding =>?
Btreity: bruise on lo;er right ar* thigh* right 'al
4aboratory results : trobo'yte +000
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4ist o robles
• -hrobo'ytopenia
•
DD: – hroni' li$er diss
– 4eu'eia
– aplasti'
– )diopathi' -hrobo'ytopeni' urpura
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Dis'ussion
"istory taing: gu bleeding =>?* bruise on herlo;er ar* right tight* and right 'al* ;eaness=>?* heada'he =>? and bloody stool =>?. atient;as diagnosed )- 6 onths ago and 'onsued
(etylprednisolon 2 g* but the dose ;asredu'ed / g 1 ;ee ago
hysi'al eaination : gu bleeding =>?* bruiselo;er right ar* thigh* right 'al =>?
4aboratory result : trobo'yte +000
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lan and -reatent
• lan: – lood sear
– one (arro; un'ture
• -reatent: – -' transusion =preedi'ation: deaethasone?
– (etylprednisolon 2 g
–
epraole 1 /0 g – )npepsa 2 10 g
– a$it D 00 g
– ara'etaol 00 g =i needed?
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rognosis
• Kuo ad #ita : dubia ad bona
• Kuo ad Fun'tiona : dubia ad bona
• Kuo ad Sanationa : dubia
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