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  • Duty Report Saturday 7th, 2015 DR - Rahmad Physician in Charge

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    Dini Jatiya Anggraini
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    Mrs. Rini S, a 36-year-old woman, presented with pale skin for one week. She has a history of thalassemia beta minor diagnosed in 2008 and has been hospitalized about 28 times for blood transfusions. On examination, she appeared moderately ill with pale conjunctiva and laboratory findings consistent with anemia. She was diagnosed with anemia due to thalassemia beta minor and treated with bed rest, a high calorie diet, IV fluids, and 2 units of packed red blood cell transfusions per day.

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    Thalassemia 06Nov2015

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    Mrs. Rini S, a 36-year-old woman, presented with pale skin for one week. She has a history of thalassemia beta minor diagnosed in 2008 and has been hospitalized about 28 times for blood transfusions. On examination, she appeared moderately ill with pale conjunctiva and laboratory findings consistent with anemia. She was diagnosed with anemia due to thalassemia beta minor and treated with bed rest, a high calorie diet, IV fluids, and 2 units of packed red blood cell transfusions per day.

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    8 views3 pages

    Duty Report Saturday 7th, 2015 DR - Rahmad Physician in Charge

    Uploaded by

    Dini Jatiya Anggraini
    Mrs. Rini S, a 36-year-old woman, presented with pale skin for one week. She has a history of thalassemia beta minor diagnosed in 2008 and has been hospitalized about 28 times for blood transfusions. On examination, she appeared moderately ill with pale conjunctiva and laboratory findings consistent with anemia. She was diagnosed with anemia due to thalassemia beta minor and treated with bed rest, a high calorie diet, IV fluids, and 2 units of packed red blood cell transfusions per day.

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    © All Rights Reserved
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    of 3

    DUTY REPORT

    Saturday 7th, 2015


    Dr.Rahmad
    Physician In Charge:
    I
    : dr. Rahmad, dr. Reza, dr. Rakhmi
    CVCU
    : dr. Somarnam
    HCU
    : dr. Gerry
    ER
    : dr. Anton, dr. Retty
    Chief
    : dr. Herman
    Consultant : dr. Shinta O.W, Sp.PD
    Summary of Data Base
    Mrs. Rini S/36 yo/w.28
    Chief Complaint: Pale
    Patient complained pale in his body about one week. Pale often
    repeated since 2008. In the year 2008,

    patient was diagnosed as

    thalassemia beta minor. She has been hospitalized about 28 times to get
    transfusion. When the pale comes, she complained of fatigue and weakness
    but does not causes shortness of breath. There was no family members who
    experienced recurrent pale or routinely transfussion. Patient has never been
    treated in hospital because of diseases other than thalassemia. The patient
    is married and has one child.
    Physical Examination
    GCS 456

    General appearance looked moderately ill

    BP 120/70mmHg PR 100 tpm

    RR 24 tpm

    Tax 35.8 C

    Head

    Anemic conjunctiva (+), Icteric (-)

    Neck

    JVP R +0 cm H2O

    Thorak Cor
    s

    Ictus invisible, palpable at ICS V 1 cm lateral MCL S


    RHM - SLD
    LHM - ictus
    S1 S2 single reguler, murmur (-)

    Lung

    Simetric, tactile fremitus was equal on both hemithorax,


    without wheezing and ronkhi

    Abdomen

    Soefl, BS (+) N, liver span 8 cm, Traubes space tympani,


    shifting dullness (-)

    Ekstremities

    warm acral, edema -/-

    Laboratory Findings (November 3rd, 2015)


    Lab
    Leucocyte
    Haemoglobi
    ne

    Value
    (Normal)

    Lab

    5,260

    3.50010.000/L

    RBS

    4.2

    11,0-16,5
    g/dl

    Ferritin

    PCV

    16.4

    35-50%

    MCV

    60.7

    80-93

    MCH

    15.6

    27 - 31

    Trombocyte

    Value
    (Normal)
    97
    5.96

    < 200
    13 150
    ng/dl

    194,000 150.000390.000/L

    Eo/bas/neu/li 1/0/68.4/2
    m/mon
    5.5/5.1

    CUE AND
    CLUE
    Mrs. Rini
    S/36
    yo/W.28
    A

    PL
    Anemia
    Gravis dt
    Thalassemia
    Beta Minor

    IDx

    PDx

    PTx
    Bed Rest
    High calorie and
    protein diet 2100
    kcal/day

    PMo
    Subj.co
    mplain
    DL
    post

    Has been
    diagnosed
    Thalassemia
    since 7 years
    ago
    Fatigue
    About 28
    times
    hospitalized
    and got blood
    transfussion
    PE
    Pale
    conjuctiva
    LAB:
    Hb 4.2
    MCV 60.7 fl
    MCH 25.6 pg

    IVFD NaCL 0.9% 20 transfu


    dpm
    tion
    Transfusi PRC 2
    kolf/day

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