Morning Report

th
May 10 , 2016
Sri Nowo Minarti
Neneng Wulandari

Internal Medicine Department

Kartika Husada Hospital
Identity
Name : Mrs. A
Age : 56 y.o
Address : Kubu Raya
Religion : Islam
Occupation : Housewife
History
Chief Complaint :
Pallor

Present Illness
Patient were administered to Kartika Husada with pallor
and weakness since 2 year ago and it getting worse since 1
week ago. Patient said that she routinely getting blood
transfusion every 1,5 months.
She also complain decrease of apetitte since 1 week ago.
Dizziness (-), vomitus and nausea (-), fever (+) since 2 days
ago but only in evening, and getting well in the night and
morning. Arthralgia (-), myalgia (-). Weight loss (+). History
of new medication taking was denied.
Past medical history
Hypertension (-)
Diabetes mellitus (-)
Hepatitis (-)
TB (-)
Gastritis (+)
Oedem in palpebra and face (-)
Oedem in lower extremities (-)
Physical Examination
Level of consciousness : compos mentis
Vital signs :
BP : 100/70 mmHg
HR : 98 beats a minute
RR : 24 breaths a minute
T : 38,2oC
 General State
Head : normocephali
Eyes : anemia (+), jaundice (-)
Nose : discharge (-), flaring nostril (-)
Neck : mass (-), lymph node enlargement (-)
Thorax :
Cor :
A : S1 S2 reguler heart sound, murmur (-), gallop (-)
 Pulmo :
I : Symetric in static and dynamic condition
P : left tactile fremitus = right tactile fremitus
P : sonor in bilateral lungs
A : VBS (+/+) in right lung and left lung, Rh (-), Wh (-)
Abdomen
I : mass (-), protuberant abdomen, caput medusa (-), spider nevi (-)
A : bowel sound (+) normal
P : tympani in all abdomen region
P : liver can be palpated 2 fingers below arcus costae, spleen enlargement (+)
schuffner line II
Extremities
Upper : warm (+/+), oedem (-/-), CRT <2 s
Lower : warm (+/+), oedem (-/-), CRT <2 s
Laboratory Examination
Hb : 6,7 gr/dl
Ht : 19,6 vol%
WBC : 82200 cells/mm3
Plt : 104000 cells/mm3
RBC : 2,33 million cells/mm3
MCV : 84,1 fl
MCH: 29,1 pg
MCHC : 34,6 g/dl
Ureum : 25 mg/dl
Creatinin : 0,7 mg/dl
 Urine macroscopic Urine microscopic
Colour : yellow Eritrocyte : 4-6 / lpb
pH : 5,0
Leucocyte : 2-4 / lpb
Leucocyte (-)
Nitrit (-) Epitel : (+)
Protein (-) Cast hyaline (+)
Glucose (-) Crystal (-)
Keton (-)
Urobilinogen (-)
Bilirubin (-)
Blood +2
Working Diagnosis
Anemia normochrom normocyter due to
1.1 Mielodysplasia syndrome
1.2 Leucemia
Treatment
Transfussion PRC 3 kolf

Suggestion :
FNAB
Check : blood smear, bone marrow biopsy
Prognosis
Ad vitam : dubia ad bonam
Ad functionam: dubia ad malam
Ad sanactionam : dubia ad malam