MORNING REPORT

Kugan Rajendran
Amanda Dinar
Claudio Wangta

Supervisor : dr Rulli Rosandi, Sp.Pd

 SUMMARY OF DATA BASE
Mrs S/31 years old/w 28bed 18
Chief complain:
Ax:Patient came to IGD with chief complaint with fatique and
headache since 3 days ago.Patient had epistaxis about 5cc of
blood yesterday right after waking up from bed but the
bleeding stopped immediately .Since 3 days ago,patient having
white stools while defecating.Patient had mild fever from 7-
11th December 2016.Patient diagnosed with thalassemia while
2nd SD class and schedulled to get blood transfusion every 2-3
months but patient not getting regular transfusion since 6
years ago.Patient only will have transfusion whenever he feels
very fatique.
 SUMMARY OF DATA BASE
History of past illness:
Patient doesn’t have other disease than thalassemia
History of medication:
No allergic medicine
Family history:
Family member doesn’t have history of thalassemia
Social history:
Patient has no occupation now. He stays with his family at home.
 Physical examination
General appearance looked mildly ill GCS 456
BP = 110/70mmHg HR = 82 bpm reguler RR =20 tpm Tax = 36.8°C

Head Pale conjungtiva Ikterik sklera (+)

(+)
Neck JVP R + 0 cm; 30°
Thorax: Cor: Invisible and palpable at ICS V and MCL Sinistra
RHM SL sinistra
LHM ≈ ictus
S1, S2 single with no murmur
Lung: Symmetric, vv Rh - - Wh - -
vv -- --
v v -- --
Abdomen Protuberant, BS (+) Normal, liverspan 14 cm, splenomegaly with
Schuffner 5 and Hackett 4
Extremities Edema -,pathologic reflex -, skin icteric, nail icteric
Lab
Laboratory finding (December, 12
Value Lab
th 2016)
Value
Hemoglobin 5,00 13,4 -17,7 g/dl GDS 112 <200 mg/dL
Erythrocyte 2,81 4,0-5,5 103/µL Ureum 32,8 10-50 mg/dL
Leukocyte 2,81 4,3-10,3 103/µL Creatinine 0,6 0,7-1,5 mg/dL

Hematocrit 16,50 40-47 % SGOT 97 0 – 41 U/L

Trombocyte 98 142-424 103/µL SGPT 101 0 – 40 U/L

MCV 58,70 80 - 93 fL Natrium 131 136-145 mmol/L

MCH 17,80 27-31 pg Kalium 3.92 3.5-5.0 mmol/L
MCHC 30,30 32 – 36 g/dL Chlorida 100 98-106 mmol/L
RDW 28,50 11,5-14,5 % Besi 98 53-167
Eu/bas/Neu/Ly/M 0,0/0,0/48/40 0-4/0-1/51-67/25- TIBC 160 300-400
o /10 33/2-5 % Saturasi 61 16-45
Tranferrin
PTT Ferritin 3427 ng/mL Dewasa : 30-400
Pasien 13,00 9,4-11,3
Kontrol 9,8
INR 1,24 <1,5
APTT
Pasien 41,80 24,6-30.6
Kontrol 26,5
 Blood smear from LAB
• Erytrocyte hipocrom micrositer,
anisopoikilocytosis(+), Target cell (+) , Tear
drop cell (+), polycromasi,normoblast(+)
• Leucocyte
Decrease count of leucocyte , neutrophenia
• Trombocyte
Decreased count of Trombocyte
 CUE AND CLUE PL IDx PDx PTx Pmo

Mrs/31 years old /w 28 bed 18 Fatigue 1.1 Anemia Hb IVFD Normal saline 500cc 30 tpm Tranfusion
Ax:Patient came to IGD with Hipokrom- electropho Tranfusion PRC 2 kolf /day until HB > Reaction,
chief complaint with fatigue
Mikrositer resis 10 Hb,
and headache since 3 days
ago.Patient had epistaxis 1.1.1 Folic Acid 1x3 tab
about 5cc of blood yesterday Thalassemia B6 /B12 3x1 tab
right after waking up from bed B mayor Paracetamol 3x 500 mg prn
but the bleeding stopped 1.1.2 Free diet high carbohydrate high
immediately .Since 3 days Deficiency protein 1700kcl/day
ago,patient having white
Iron
stools.Patient had mild fever
from 7-11th December 2016.
Patient diagnosed with
thalassemia while 2nd SD class
and schedulled to get blood
transfusion every 2-3 months
but patient not getting regular
transfusion since 6 years ago.

PE:Icteric sclera +,conjunctiva

anemis +,abdomen
protuberent ,liver span
14cm,splenomegaly schuffner
5-Hacket 4

Lab :Hb 5,10,RBC 5.93,WBC

3,20,HCT 16,70,PLT 68,MCV
57,MCH 17,40,MCHC
30,50,RDW 28,40, SI 98, TIBC
160, Ferritin 3472, Saturasi
Tranferrin 61
 Patient Condition This Morning
• BP : 110/60
• HR : 70 bpm
• RR : 20
• Tax : 36.8
Thank You