anggia dian - aml
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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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