MORNING REPORT

Dr. Zainudin

Monday, 2nd Sept 2013

PHYSICIAN IN CHARGE:

I A : dr. Zainudin, dr Dian I B : dr.Deddy , dr. Dian II : dr. Sigit Triyus III : dr. Sri Sunarti, Sp.PD

Moderator : dr. Atma Gunawan, Sp.PD-KGH

SUMMARY OF DATA BASE

Female/45yo/W25 Chief complain : General Weakness Patient suffered from general weakness since 1 month ago after she discharged from RSSA, patient can only do her daily activity in her bed. General weakness worsened in 3 days before admission and accompanied with gum bleeding. Patient also complained about nausea, vomiting and decrease of appetite since 3 days before admission. Patient only drink water without taking meal. Patient also suffered from spontaneous bruise in her leg since 1 week ago. Bruise is got better by itself.

SUMMARY OF DATA BASE

History of past illness : Patient was diagnosed leukemia in july 2013 and got tranfusion also with pill for her high blood count. Patient was never hospitalized before There is no history of DM and HT. Family History: Her mother got hypertension. There is no family member with blood disorder Social history : Patient was married with 4 children and got 4 siblings. Patient is a housewive.

PHYSICAL EXAMINATION
BP : 130 /70 (ward) PR : 120 strong (ward) RR : 18 tpm, Tax : 36,3 0C

General appearance : looked moderately ill Head Neck Thorax : Cor

GCS 456 ; Looked overweight

Pale conjunctiva + , icterus +, Lymp enlargement (-), gingival bleeding (+) R+ 2 cm H2O (30) Ictus visible and palpable at ICS V MCS sinistra LHM ~ ictus RHM: parasternal line D S1, S2 single m(-) g(-) Symmetric, vesicular at all area, rhonci (-), wheezing (-) soefl, bowel sound normal, liver span 8 cm, Schuffner VI, bowel sound + normal Warm acral, no edema, bruise in lower extremity

Pulmo Abdomen Extremities

LABORATORY FINDINGS
Lab
Leucocyte
Diff Tell - blast Haemoglobin MCV MCH PCV Thrombocyte SGOT/AST SGPT/ALT Alb

Value

Lab
Na
K Cl

Value

242.770
0/3/1/14/ 4/0 73% 5,8 87,6 31,4 16,2 14.000 156 147 3,72 1582

4000-11.000/L
0-4/0-1/51-67/2533/2-5 % 11-16,5 g/dL 80-93 fl 27-31pg 40-47 % 150-450x103/L 11-41U/L 11-41U/L 3.5-5.5 g/dL

125
4,41 97

136-145mmol/l
3,5-5,0 mmol/l 98-106 mmol/l

Osm

258

Ureum Creatinin RBS

24 0,65 100 7,6

16,6-48,5 mg/dL < 1,2 mg/dL < 200 mg/dL

Uric acid

3,4-7 mg/dL

LDH

240-480

URINALISIS
Lab
Cloudy
Color pH BJ Glucose

Value
Cloudy
Yellow 7,0 1,010 -

Lab
Clear
Yellow 4,5 - 8,0 1,010 1,015 Negative

Value
1,7 1lpf Lpf 2 Negative

10 x
Epitel Cilinder Hialin Granular 40 x Erythrocyte Dysmorfic 12,9 3 hpf Hpf

Protein
Keton Bilirubin

+2
+2 +3 -

Negative
Negative Negative

+
22,5 374,4

Urobilinogen
Nitrit

Negative
Negative

Eumorfic
Leucocyte Cristal Bacteria

Hpf
5 hpf hpf 23 x 103/mL

Leucocyte
Blood

Trace
+3

Negative
Negative

Blood Smear (1/9/13)

CXR (1/9/13)
AP position, symetric, KV enough, less inspiration Trachea in the middle Soft tissue and bone normal Right and left phrenico-costalis angle are sharp Right and left hemidiaphragm are dome-shaped, Bronchovascular pattern normal Cor site N, size : CTR 55 % , heart waist (+) Conclusion : normal chest x ray

ECG (1/9/13)
Sinus rhythm, Heart rate 125 bpm Frontal Axis : Normal Horizontal Axis : counter clock wise rotation PR interval : 0.16 QRS complex : 0.08 QT interval : 0.36 Conclusion : Sinus tachycardia with HR 125 bpm

CUE AND CLUE

Female/ 45 yo/W 25 Ax : General weakness Gingival bleeding Bruise Abdominal discomfort Nausea vomiting Px : PR : 120 tpm Anemia Icterus Spleen shcuffner VI Bruise in leg Lab : Hb : 5,8 mg/dL MCV/MCH 87,6 fl/31,4 Leucocyte : 217.770 Thrombocyte : 14.000/uL Diff count : 0/3/1/14/4/0 Blood smear sel muda 73%, promyelosit 4%, myelosit 1%, normoblas 14/100 lekosit

PL
1. CML Blast Phase

IDx

PDx
BCR ABL BMP

PTx
Rehydration with IVFD NaCl 0,9% 1 L continued with 30 dpm

PMo

TC transfusion 2 packs/day until Thrombocyte > 30.000/uL and bleeding stop

PRC tranfusion 2 packs/day until Hb level > 10gr/dl

Cytoreduction with Po hydroxyurea 4x1000mg

CUE AND CLUE

Female/ 45 yo/W 25 Ax : Abdominal discomfort Nausea vomiting Px : Spleen shcuffner VI

PL
2. Dyspepsia syndrome

IDx
2.1 organomegaly 2.2 Paraneoplastic syndrome 2.3 Peptic ulcer disease 2.4 congestive liver

PDx

PTx
Inj metoclopramide 3x10mg Po omeprazole 3x10 mg

PMo
subjecti ve

CUE AND CLUE

Female/ 45 yo/W 25 Lab : Uric acid 7,6

PL
3. hyperuric emia

IDx
3.1 lysis syndrome

PDx

PTx
Po Allopurinol 1x300mg Po. Nabic 3x500mg

PMo
subjecti ve

CUE AND CLUE

Female/ 45 yo/W 25 Ax : Nausea vomiting

PL
4. Hyponatr emia hypoosm olar hypovole mia

IDx
4.1 GI Loss 4.2 Poor Intake

PDx

PTx
IVFD NaCl 0,9% 30 tpm (as above)

PMo
subjecti ve

Px : PR : 120 tpm
Lab : Na : 125 mmol/L Osm : 258

CUE AND CLUE

Female/ 45 yo/W 25 Ax : Nausea Vomiting Abdominal discomfort Px : Icteric sclera Lab : OT/PT 156/147 U/L Albumin 3,72 g/dL ALP 115 U/L Y GT 122 U/L HBsAg AntiHCV

PL
5. Elevated Liver Enzyme

IDx
5.1 Congestive liver 5.2 Leukostasis 5.3 Reactive 5.4 extramedullary hematopoetic

PDx
Abdominal USG

PTx
Confirm diagnose

PMo
Subjecti ve, icteric,

bilirubi
n,

Problem Analysis
Organomegaly Congestive liver Splenomegaly

Extramedullary hematopoetic

Dyspepsia syndrome
Dyspepsia syndrome Poor Intake

CML Thrombocytope nia Gum Bleeding

Leukositosis

leukostasis

Anemia

General Weakness

Management analysis
Urgency : Thromboncycytopenia with bleeding TC tranfusion Anemia N-N PRC tranfusion Hyponatremia hypoosmolar hypovolemia rehydration and fluid infusion of NaCl 0,9% Non Urgency : Dyspepsia syndrome injection of prokinetic agent and Proton pump inhibitor

Risk Factor Analysis

CML
Radiation Chemical exposure Chemotherapy Gender Genetic

Condition this morning : GCS 456 BP 130/80 PR 100 bpm RR 18 tpm Urine prod : 300cc/9 hour

Thank You