MORNING REPORT

Saturday, August 21’th 2010

PHYSICIAN INCHARGE:
IA : dr. Nicholas dr. Meci
IB : dr. Didin, dr. Leny
II : dr. Maya
III : dr. Sri Sunarti, SpPD
 Summary of Data Base

Male/ 14 yo/ W 27

Chief Complain : gum bleeding

Patient had gum bleeding since yesterday while he was
sleeping. He woke up because he felt liquid drooling out
of his mouth. The volume of the bleeding was about
quarter of a glass. He also felt hypertrophy of his gum
since yesterday.
His parents then took him to Bangil hospital. He got 1
pack of Whole Blood transfusion. Then he was referred
to RSSA because there was no specific component of
Patient never had this kind of situation before. He never
had a bleeding that difficult to stop.

Since yesterday, patient had petechiae on his skin.

There was no nodule that he felt at his body.
His urine and stool was normal, there were no blood.

He has a good appetite.

He had headache since 2 days ago.
 Physical examination
BP = 100/70 mmHg PR = 88 bpm RR = 20 tpm Tax : 36,4 °C

General appearance looked moderately ill GCS 456

Head Anemic - Icteric -
Neck JVP R + 0 cm; 30°
Thorax: Cor: Ictus invisible and palpable at MCL ICS V Sinistra
RHM SL Dextra
LHM ≈ ictus
S1, S2 single with no murmur

Lung: Symmetric, SF D = S, v v Rh - - Wh - -
vv -- --
vv -- --

Abdomen Soft, liver span 8 cm, troube space tympani

Extremities Warm, ptechiae(+)

 Laboratory finding
Lab Value Lab Value
Leukocyte 6.800 3.500- Natrium 141 136-145 mmol / L
10.000/µL

Haemoglobine 11,6 11,0-16,5 g/dl Kalium 3,62 3,5-5,0 mmol / L

PCV 34,7 35-50% Chlorida 114 98-106 mmol / L

Trombocyte 16.000 150.000- RBS 83

390.000/µL

SGOT 19 11-41U/L Ureum 23,7 10-50 mg/dL

SGPT 13 10-41U/L Creatinine 0,38 0,7-1,5 mg/dL

Dengue IgG + Dengue IgM +

aPTT 48,9” (K:23,9”)

 CUE AND CLUE PL IDx PDx PTx PMo

Male/14 yo 1.Gum 1.1.ITP Blood •Free diet Subjec

•Gum bleeding bleeding 1.2.Alekemic smear •Vit K 3x1amp (iv) tive
•Gum hypertrophy +thromb leukemia BMP •Folic acid 1x3tab BP
•No history before ocytopen 1.3.ALL •B6B12 3x1tab HR
•Ptechiae+ ia 1.4.DHF grade •TC transfusion 10cc/kg BW RR
•Tr:16.000 2 continue with FFP transfusion CBC
•Dengue IgM+ 10 cc/kgBW Hemos
•Dengue IgG+ tatic
•Prolonged functio
haemostatic function n
Thank you