CASE REPORT

IDIOPATHIC THROMBOCYTOPENIA PURPURA

Ayu Wulan Anggreni 030.05.046

IDENTITY
Name Age Address Job Last Education

Marital Status
Religion Ethnic

Date of Admission
Taken From

: Mr.W : 44 years old : Tegawaru, Karawang : Labor : junior high school : Married : Islam : Sunda : 18 April 2012 : Rengasdengklok

ANAMNESIS
AUTOANAMNESIS (on April 13th, 09.00am)
Main Complaint: Bleeding gums since 1 week

before admitted to the hospital

Additional complaint:
Pain and bruises on the arms, chest and the waist Nausea

HISTORY OF PRESENT DISEASE (1)

Mr. W, 44-years-old labor, came to emergency department of RSUD

Karawang after experiencing bleeding in the gums since 1 week

before admitted to the hospital. This bleeding came out from the lower
middle front and upper left back of the gum. The blood sometimes came out thick and clotted, and it bleeds without any trauma prior to it, like brushing the teeth forcefully.
Patient also complained the pain and bruises on almost all over his

body. 1 week before admitted to the hospital. in his arms, chest and his waist, he experienced unknown sharp pain, followed by reddish-

purple bruises on the same area appeared around 2 days before

admitted to the hospital. The bruises appeared without any trauma history as well, and theyre still havent disappeared yet. Patient also complained nausea since 3 days before admitted to the hospital.

HISTORY OF PRESENT DISEASE (2)

he was not experiencing any fever, abdominal pain, arthralgia nor

bleeding from her nostril he didnt have any complaint from his
urinating and defecation. he denied any blood appearance or any black color in his stool and his urine.

HISTORY OF PAST DISEASE

Same illness (-)

Hypertension ()
DM () Allergy () Asthma ()

FAMILY HISTORY
Same illness ()

Hypertension ()
Diabetes Mellitus ()

Allergy ()
Asthma ()

MEDICATION HISTORY
Blood transfusion ()

Surgery ()
Other medication ()

PERSONAL AND SOCIAL HISTORY

he didnt regularly exercise.

He is a regular smokers since 20 years ago

no consumption of alcohol or drugs

No consumption of herbal drink

GENERAL CONDITION
General Appearance Consciousness

: Mildly ill : Compos mentis

VITAL SIGNS
Blood Pressure Heart Rate Respiration Rate Temperature

: 110/80 mmHg : 72 times/minute : 18 times/minute : 36,8oC

GENERAL STATUS
Head Normocephali Eyes Pupil isokor, DLR +/+, UDLR +/+, CA +/+, SI -/- , Ears Normotia, secrete -/-, blood -/-, serumen -/ Nose septum deviation (-), secrete -/-, blood -/-, concha normal, mucosa not hyperemic

GENERAL STATUS
Mouth
dry mouth (+), cyanosis lip (-), dirty tongue (-),

normal papil, mucosa hyperemic (-), gingival bleeding (+)

Throat
Tonsils T1/T1 calm, pharynx hyperemic (-)

Neck
Lymph nodules not palpable, tiroid gland not

palpable, JVP 5+2 cm H20

THORAX EXAMINATION
Lung Examination
Inspection
Palpation Percussion Auscultation

: Symmetrical
: Equal vocal fremitus : Sonor : Vesicular breath sound in both

lung, no ronchi and wheezing

THORAX EXAMINATION
Heart examination
Inspection

: Petechie (+)

o Ictus cordis is invisible

Palpation

: Ictus cordis is palpable at 5th ICS

LMCS
Percussion

: No enlargement of the

heart
Auscultation

: Regular I - II heart sound, no murmur and gallop

ABDOMINAL EXAMINATION
Inspection
Flat, symmetric, caput medusa (-), smiling umbilicus (-), petechiae

(+)

Palpation
Tenderness (+)

Distension (-)
No liver and spleen enlargement Murphy sign (-)

Percussion
Tympanic
No pain present on abdominal percussion

Auscultation
Bowel sound (+) normal, arterial bruit (-), venous hum (-)

EXTREMITY EXAMINATION
- Warm Acral

+ +

+ +

- Oedem

- Multiple purpura & petechiae

+ +

+ +

LABORATORY EXAMINATION
April 14th 2012
RESULT Hemoglobin Leucocytes Thrombocytes Ht Bleeding Time Clotting Time 8,8 6,300 47.000 29 3 13 Normal Range (12 17) g% (5.000 10.000)/L (150.000 450.000)/L (37 48) % (1 4) Minutes (9 15) Minutes

Random Blood Glucose

Ureum Creatinine

90
23,7 0,65

(80 140) mg/dl

(10 45) mg/dl (0,4 1,5) mg/dl

LABORATORY EXAMINATION
April 17th 2012
RESULT Hemoglobin Leucocytes Thrombocytes Ht Differential Count Basophil Eosinophil Rod Neutrophil 0 0 0 (0 1) % (1 3) % (2 6) % 9,6 8.300 50.000 29 Normal Range (12 17) g% (5.000 10.000)/L (150.000 450.000)/L (37 48) %

Segment Neutrophil
Lymphocyte Monocyte MCV

65
32 3 79

(50 70) %
(20 40) % (2 8) % (82 92) UI

RESUME
SYMPTOMS Gingival bleeding 7 days before hospitalized Pain and bruises on the waist, arms and chest 3days before hospitalized Skin rash on the stomach, arms and chest petechiae and purpura SIGNS Vital sign T : 36,8oC Mouth gingival bleeding (+) Abdomen petechia (+), petechua (+) on the waist Upper and Lower Extremities multiple petechia and purpura (+) LABORATORY AND OTHERS Complete Blood Count Anemia Thrombocytopenia

DIFFERENTIAL DIAGNOSIS
Idiopathic Thrombocytopenia Purpura Aplastic Anemia Dissaminated Intravascular Coagulation Drug induced Thrombocytopenia

WORKING DIAGNOSIS

Idiopathic Thrombocytopenia Purpura

SUGGESTED EXAMINATION
Reticulocyte Count Iron Serum Total Iron Binding Capacity Bone Marrow Aspiration

Immunology Test

TREATMENT
IVFD NaCl 0,9 % 30 drops/minute

Methylprednisolon 2 x 125 mg injection

Ranitidin 2 x 1 injection

Neurodex tablet 2 x 1
Vitamin C tablet 3 x 1

PROGNOSIS
Ad Vitam

: Dubia ad bonam

Ad Functionam : Dubia ad bonam Ad Sanationam : Dubia ad malam