Oleh :

M.Iqbal Al Islamy
14A013056
 Patient Identity

 Name : Mrs. S
 Sex : female
 Age : 24 y.o
 Religion : Islam
 Tribe : Banjar
 Nation : Indonesia
 Address : Tanjung rawa
 Occupation :-
Date of Hospitalization : 13 september 2017
 Autoanamnesis
Keluhan Utama: perdarahan pervaginam


Autoanamnesis:

Pasien rujukan dari RS ratu zaleha dengan keluhan

perdarahan pervaginam sejak 3 minggu sebelum masuk
rumah sakit (smrs). pasien di rawat di rs ratu zaleha
selama 1 minggu dengan keluhan perdarahan
pervaginam, di rs sebelumnya pasien diperiksa MDT dan
hasilnya curiga aml. Saat datang pasien mengeluhkan
perdarahan pervaginam berupa darah segar, pusing,
batuk hilang timbul sejak sebelum dirawat drs, selain itu
terdapat benjolan-benjolan kecil di leher pasien. Pasien
tidak menderit tekanan darah tinggi ataupun diabetes
mellitus. Pasien riwayat melahirkan 1 bulan smrs.
 Autoanamnesis

 History of past illness: -

 History of family illness: -

 History of drug: (-)

 Allergic History : (-)

 Smoking History: (-)

 Physical Examination (August 13st 2017 )
TD: 100/60 mmHg HR: 110 x/mnt reguler, RR : 22x/mnt reguler Tax : 37.5 0C SpO2 9
%
General appearance : tampak sakit berat GCS 4-5-6
Head
Neck

Konjungtiva pucat (+/+)
JVP R+4cmH2O, pembesaran kelenjar limfa (+) di anterior cervical 4 bua
dengan diameter +- 3 cm , konsistensi kenyal.
Thorax ( Pulmo ) I : Simetris
Pal : Simetris, fremitus fokalis D=S
Per : Sonor
A:VV Rh - - Wh - -
VV - - - -
VV - - - -
Cor I : Ictus tidak terlihat
Pal : Ictus teraba di linea axilla anterior sinistra ics V
Per : LHM : ICS V Linea axilla anterior Sinistra
RHM : ICS V Linea sternalis dextra
A: S1 S2 single, Murmur (+)
Abdomen Bu (+), liver span 14 cm, troube space redup, schuffner 2,
massa (-)
Abdominal pain
+--
--- 
---

Extremities M 5 5 Pitting Edema - -

5 5 - -
X-ray thorax

Thorax AP
Tampak corakan bronchovesicular normal
Tak tampak pelebaran kedua pleural space
Kedua diafragma licin dan tak mendatar
Cor, CTR 83%

Kesan :
Pulmo tak tampak kelainan
cardiomegaly
 BMP 19-9-2017

 August, 18 th 2017
 Normal exam with Full Filled Bladder
 Laboratory Result 2-10-2017

Pemeriksaan Hasil Nilai Rujukan Satuan Metoda

HEMATOLOGI
Hemoglobin 4.2 12,50-15,60 g/dl Colorimetric
Leukosit 163.79 4,65-10,3 thousand/ul Impedance
Eritrosit 1.83 4,10-6,00 milion/ul Impedance
Hematokrit 15.5 42,00-52,00 Vol% Analyzer Calculates
Trombosit 24 150-356 Ribu/ul Impedance
RDW-CV 14.5 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 84.8 75,0-96,0 Fl Analyzer Calculates
MCH 23.0 28,0-32,0 Pg Analyzer Calculates
MCHC 27.1 33,0-37,0 % Analyzer Calculates
 Laboratory Result 29-09-2017

Pemeriksaan Hasil Nilai Rujukan Satuan Metoda

HEMATOLOGI
Hemoglobin 2.0 12,50-15,60 g/dl Colorimetric
Leukosit 283.11 4,65-10,3 thousand/ul Impedance
Eritrosit 1.49 4,10-6,00 milion/ul Impedance
Hematokrit 13.3 42,00-52,00 Vol% Analyzer Calculates
Trombosit 12 150-356 Ribu/ul Impedance
RDW-CV 34.1 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 89.2 75,0-96,0 Fl Analyzer Calculates
MCH 13.4 28,0-32,0 Pg Analyzer Calculates
MCHC 15 33,0-37,0 % Analyzer Calculates
Laboratory Result 27-09-2017
 Laboratory Result 25-09-2017
Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
HEMATOLOGI
Hemoglobin 9.8 12,50-15,60 g/dl Colorimetric
Leukosit 366.1 4,65-10,3 thousand/ul Impedance
Eritrosit 2.01 4,10-6,00 milion/ul Impedance
Hematokrit 17.5 42,00-52,00 Vol% Analyzer Calculates
Trombosit 37 150-356 Ribu/ul Impedance
RDW-CV 16,6 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 87.1 75,0-96,0 Fl Analyzer Calculates
MCH 48.7 28,0-32,0 Pg Analyzer Calculates
MCHC 56 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 35.8 50,0-70,0 % Impedance
Limfosit% 44.1 25,0-40,0 % Impedance
Gran# 131.1 2,50-7,0 ribu/ul Impedance
Limfosit# 161.5 1,25-4,0 ribu/ul Impedance
 Laboratory Result 19-09-2017
Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
HEMATOLOGI
Hemoglobin
Leukosit
Eritrosit
9.6
327.4.1
2.39

12,50-15,60
4,65-10,3
4,10-6,00
g/dl
thousand/ul
milion/ul
Colorimetric
Impedance
Impedance
Hematokrit 20.3 42,00-52,00 Vol% Analyzer Calculates
Trombosit 41 150-356 Ribu/ul Impedance
RDW-CV 17 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 85 75,0-96,0 Fl Analyzer Calculates
MCH 40.1 28,0-32,0 Pg Analyzer Calculates
MCHC 47.2 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 32.1 50,0-70,0 % Impedance
Limfosit% 48 25,0-40,0 % Impedance
Gran# 105.1 2,50-7,0 ribu/ul Impedance
Limfosit# 157.2 1,25-4,0 ribu/ul Impedance
 Laboratory Result 19-09-2017
Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
HEMATOLOGI
Hemoglobin 9.7 12,50-15,60 g/dl Colorimetric
Leukosit 308.5 4,65-10,3 thousand/ul Impedance
Eritrosit 2.17 4,10-6,00 milion/ul Impedance
Hematokrit 17.9 42,00-52,00 Vol% Analyzer Calculates
Trombosit 26 150-356 Ribu/ul Impedance
RDW-CV 16.6 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 82.7 75,0-96,0 Fl Analyzer Calculates
MCH 44.7 28,0-32,0 Pg Analyzer Calculates
MCHC 54.1 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 26.0 50,0-70,0 % Impedance
Limfosit% 54.2 25,0-40,0 % Impedance
Gran# 80.20 2,50-7,0 ribu/ul Impedance
Limfosit# 167.2 1,25-4,0 ribu/ul Impedance
 Laboratory Result 14-09-2017
Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
HEMATOLOGI
Hemoglobin 10.3 12,50-15,60 g/dl Colorimetric
Leukosit 306.6 4,65-10,3 thousand/ul Impedance
Eritrosit 2.41 4,10-6,00 milion/ul Impedance
Hematokrit 19.9 42,00-52,00 Vol% Analyzer Calculates
Trombosit 46 150-356 Ribu/ul Impedance
RDW-CV 15.9 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 82.7 75,0-96,0 Fl Analyzer Calculates
MCH 42.7 28,0-32,0 Pg Analyzer Calculates
MCHC 51.7 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 22.9 50,0-70,0 % Impedance
Limfosit% 57.3 25,0-40,0 % Impedance
Gran# 70.2 2,50-7,0 ribu/ul Impedance
Limfosit# 175.7 1,25-4,0 ribu/ul Impedance
 Laboratory Result 13-09-2017
Pemeriksaan Hasil Nilai Rujukan Satuan Metoda
HEMATOLOGI
Hemoglobin 9.1 12,50-15,60 g/dl Colorimetric
Leukosit 388.9 4,65-10,3 thousand/ul Impedance
Eritrosit 2.00 4,10-6,00 milion/ul Impedance
Hematokrit 16.4 42,00-52,00 Vol% Analyzer Calculates
Trombosit 47 150-356 Ribu/ul Impedance
RDW-CV 16.6 12,1-14,0 % Analyzer Calculates
MCV, MCH, MCHC
MCV 82.1 75,0-96,0 Fl Analyzer Calculates
MCH 45.5 28,0-32,0 Pg Analyzer Calculates
MCHC 55.4 33,0-37,0 % Analyzer Calculates
HITUNG JENIS
Gran% 34.5 50,0-70,0 % Impedance
Limfosit% 39.4 25,0-40,0 % Impedance
Gran# 99.70 2,50-7,0 ribu/ul Impedance
Limfosit# 113.8 1,25-4,0 ribu/ul Impedance
 Pemeriksaanv Hasil Nilai Rujukan Satuan Metoda
GULA DARAH
GDS 99 c <200 MG/DL GOD-PAP

HATI
albumin 1,73 3.5-5.5 g/dl Buret
SGOT 27 0 - 46 U/l IFCC
SGPT 32 0 - 45 U/l IFCC
IMUNO-SEROLOGI
AFP > 400.0 <10.0 Ul/ml 1-step EIA
sandwich + E
Ginjal
Ureum 14 10-50 Mg/dl Modiff berhelot
Creatinin 0.6 0,6-1,2 Mg/dl Jaffe
 ECG


Sinus rhythm, regular, Heart rate 100 x/m

Frontal axis: normal
Horizontal axis: V3 Normal
PR interval : 0.12 second
QRS complex : 0.08 second
LVH (-)
Conclusion : sinus rytm
 CUE AND IDx PDx PTx PMo Ped
CLUE
Ax: 1. AML- M0 Ivfd Ns 30 tpm DR Higienitas
Perdarahan Inj. Metilprednisolon 2x1
pervaginam, lemas, Inj ranitidin 2x1
batuk berdahak hilang Inj kalnex 3x500


timbul Inj antrain (k/p)
Px Fisik: Po. Cytodrox 1x500 mg
Konjungtiva pucat Po. Codein 3x20 mg
(+/+) Po. NAC 3x250 mg
Pembesaran kelenjar Po. Hydroxiurea 4x500 mg
cervical konsistensi Po. Imuran 2x1 tab
kenyal Po. Cefixime 2x200 mg
Lab:
Bisitopeni
Leukositosis
AFP >400
BMA: tampak acute
myeloblastic lukemia
tipe M0 (AML-M0)
 Follow up

14 september 2017:
S) Batuk (+), nyeri dada kanan (+) sesak (+) BAK/BAB(+)
mimisan (-)
O) CM, TD 110/80, N68x/mnt, R 28x/mnt, T 36.8oC
A) Leukositosis susp AML dd AML
P) IVFD Nacl 30 tpm
inf metilpradnisolon 125 mg 2x1
inf ranitidin 2 x 1
inj ceftazidime 3 x 1
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up

15 september 2017:
S) Batuk (+), nyeri dada kanan (+) sesak (+) BAK/BAB(+) mimisan (-)
O) CM, TD 100/80, N80x/mnt, R 19x/mnt, T 37oC /SPO2 96%
A) Leukositosis susp AML dd AML
P) IVFD NS 20 tpm
O2 2-4 lpm
inf metilpradnisolon 125 mg 2x1
inf ranitidin 2 x 1
inj ceftazidime 3 x 1
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up

16 september 2017:
S) sesak (+) sakit miring kanan (+) BAK/BAB(+) mimisan (-)
O) CM, TD 90/60, N97x/mnt, R 20x/mnt, T 36,9oC /SPO2 99%
A) Leukositosis susp AML dd AML
P) IVFD NS 20 tpm
O2 2-4 lpm
inf metilpradnisolon 125 mg 2x1
inf ranitidin 2 x 1
inj ceftazidime 3 x 1
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up

17 september 2017:
S) sesak (+) BAK/BAB(+) mimisan (-)
O) CM, TD 110/70, N99x/mnt, R 20x/mnt, T 37,3oC /SPO2 98%
A) Leukositosis susp AML dd AML
P) IVFD NS 20 tpm
O2 2-4 lpm
inf metilpradnisolon 125 mg 2x1
inf ranitidin 2 x 1
inj ceftazidime 3 x 1
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
20 september 2017:
S) sesak (+) BAK/BAB(+) mimisan (-)
O) CM, TD 110/70, N99x/mnt, R 20x/mnt, T 37,3oC /SPO2 98%
A) AML M0
P) IVFD NS : aminofusi (2:1) 20 tpm
O2 8 lpm NRBM
inf metilpradnisolon 125 mg 2x1 (+) Hidroxil 4 x 500 mg
inf ranitidin 2 x 1 (+) diet lunak
inj ceftazidime 3 x 1 (+)mikamiki
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
22 september 2017:
S) sesak ( +) BAK/BAB(+) mimisan (-) nyeri perut (+)
O) CM, TD 100/60, N93x/mnt, R 18x/mnt, T 36,3oC /SPO2 96%
A) AML M0
P) IVFD NS : aminofusi (2:1) 20 tpm
O2 8 lpm NRBM
inf metilpradnisolon 125 mg 2x1 (+) Hidroxil 4 x 500 mg
inf ranitidin 2 x 1 (+) diet lunak
inj ceftazidime 3 x 1 (+)mikamiki
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
23 september 2017:
S) pusing (+)
O) CM, TD 100/60, N91x/mnt, R 20x/mnt, T 36,7oC /SPO2 97% rh (+) lapang paru
kanan bawah
A) 1. Anemia ec AML M0
2. pneumonia HAP
P) IVFD NS : aminofusi (2:1) 20 tpm
O2 8 lpm NRBM
inf metilpradnisolon 125 mg 2x1 (+) Hidroxil 4 x 500 mg
inf ranitidin 2 x 1 (+) diet lunak
inj ceftazidime 3 x 1 (+)mikamiki
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
25 september 2017:
S) pusing (+) keringat dingin, pucat (+) mata kabur (+)
O) CM, TD 90/60, N100x/mnt, R 32x/mnt, T 38oC /SPO2 97% rh (+) lapang paru kanan
bawah
A) 1. Anemia ec AML M0
2. pneumonia HAP perbaikan
3. pendarahan mata
P) IVFD NS 200 cc/30 menit (cek ulang tensi ). Jika tensi naik NS 20 tpm
O2 10 lpm NRBM
inf metilpradnisolon 125 mg 2x1 (+) Hidroxil 4 x 500 mg
inf ranitidin 2 x 1 (+) diet lunak
inj ceftazidime 3 x 1 (+)mikamiki
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
26 september 2017:
S) Lemah (+) mata mulai melihat ,konj. Anmeis (+/+)
O) CM, TD 100/60, N96x/mnt, R 24x/mnt, T 36.6oC /SPO2 98% rh (+) lapang paru
kanan bawah
A) 1. Anemia ec AML M0
2. pneumonia HAP perbaikan
3. pendarahan mata
P) IVFD NS 20 tpm
O2 10 lpm NRBM
inf metilpradnisolon 125 mg 2x1 (+) Hidroxil 4 x 500 mg
inf ranitidin 2 x 1 (+) diet lunak
inj ceftazidime 3 x 1 (+)mikamiki
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
28 september 2017:
S) Gusi bengkak dan nyeri, sulit makan, perdaraham pervaginam
O) CM, TD 100/60, N92x/mnt, R 26x/mnt, T 38.3oC /SPO2 96% rh (+) lapang paru
kanan bawah
A) 1. AML M0
2. hipertrofi gingifa
3. cardiomyopati post partum
4. retina bleeding
P) IVFD NS 20 tpm
O2 10 lpm NRBM
inf metilpradnisolon 125 mg 2x1 (+) vit K 3 x 1 tab
inf ranitidin 2 x 1
inj ceftazidime 3 x 1
inj kalnex 3 x 500 mg
Inj antrain K/P
p.o cytodrox 1 x 500mg p.o Hidroxil 4 x 500 mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
29 september 2017:
S) Gusi berdarah, sulit makan, perdaraham pervaginam
O) CM, TD 100/60, N106x/mnt, R 20x/mnt, T 37.3oC /SPO2 99% rh (+) lapang paru
kanan bawah
A) 1. AML M0
2. hipertrofi gingifa
3. cardiomyopati post partum
4. retina bleeding
5. bleeding gingifa
P) IVFD NS 20 tpm
O2 10 lpm NRBM
inf metilpradnisolon 125 mg 2x1 inj. As.traneksamat 3 x 500 mg
inf ranitidin 2 x 1 tranfusi TC 10 kolf
inj ceftazidime 3 x 1 tranfusi PRC 1 kolf/hari (premed inj.furosemid ½ amp)
inj kalnex 3 x 500 mg
Inj antrain K/P p.o vit K 3 x 1 tab
p.o cytodrox 1 x 500mg p.o Hidroxil 4 x 500 mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
2 oktober 2017:
S) Demam (+) sesak nafas(+)
O) CM, TD 100/60, N123x/mnt, R 26x/mnt, T 37.6oC /SPO2 95%
A) 1. AML M0
2. anemia gravis
3. cardiomyopati post partum
4. retina bleeding
5. bleeding gingifa
P) IVFD NS 20 tpm
O2 10 lpm NRBM
inf metilpradnisolon 125 mg 2x1 inj. As.traneksamat 3 x 500 mg
inf ranitidin 2 x 1 tranfusi TC 10 kolf
inj ceftazidime 3 x 1 tranfusi PRC 1 kolf/hari (premed inj.furosemid ½ amp)
inj kalnex 3 x 500 mg
Inj antrain K/P p.o vit K 3 x 1 tab
p.o cytodrox 1 x 500mg p.o Hidroxil 4 x 500 mg
p.o codein 3 x 200 mg p.o NAC 3 x 250
 Follow up
19.20 pm  19.50 Am
Kelurga mengatakan pasien kejang kurang
lebih 10 menit. Kejang (+)
TD : 60/40 TD : 40/palpasi
HR : 137
RR : 12 HR : 60
T: 40 RR : 11
SpO2 : 84 % dgn 10 lpm NRBM
 Kejang fokal toniklonik T: 40.1
 Mata terbalik keatas SpO2 : 78 % dgn 15 lpm
Tindakan
Membebaskan jalan nafas
Menaikan o2 15 lpm
Konsul dpjp (+)
 Follow up
 19.55 pm

Kelurga(+)
TD : -
HR : -
RR : 5
T: 40
SpO2 : - % dgn 15 lpm NRBM
 Kejang fokal toniklonik
 Mata terbalik keatas

Tindakan
RJP 5 siklus
 
20.01 pm
 Pasien dinyatakan meninggal di hadapan keluarga,
parameds, dan dokter muda.
 Penyebab kematian:
 1. hipoksia
 1.1 leukostasis
 1.2 status epileptikus