Anemia Ec MM

7/28/2019 Anemia Ec MM

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Anamnesis

Autoanamnese pada 6

7Agustus 2012 jam 10.00

Alloanamnesis dengan Tn A(suami) 7 Agustus 2012 jam

12.00


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IDENTITY Ny. YName 31 years oldAge

FemaleSex

Dusun I Krajan 01/01 Pasir Tanjung, Karawang

Address Elementary school

Education

HousewifeOccupation

IslamReligion MarriedMarital status

July 30 th 2012Admitted

RengasdengklokTaken from


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INTERVIEW

MAIN COMPLAIN

ADD COMPLAIN

Nausea, Vomit, No

defecation since 7 daysbefore hopitalized, Hardto moving, Dizziness, and

Backache,and Weak

Difficulty of breathingsince 2 days before

hospitalized


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History Of Present Illness

A patient came to Emergency Unit RSUD Karawang with

a complaint of difficulty of breathing since 2 days ago. The

symptom first always appeared in the night but now its

appeared whole of the days. Patient feels airless and also

dizziness especially in her backhead. She also complaintalways got cough without split, and got nausea and

vomite everyday since 1 week before hospitalized. No

defecation until 1 week and feel so weak.


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She also complained of having pain in her back

and also cant moving for 3 months before hospitalized.

She confessed that before it happen, one day when she

just woke up, she move her chest usual after sleep andsuddenly she remembered there was a huge sound like

something broken and also without pain. At first it looked

normal, but after 3 months, she cant move her upper body

until now (7 August) and it getting worse


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Picture of Patient


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History of Past Illness

Tuberculosis

(-)

Bone Disease

(-)

Trauma

(-)

Diabetic

Mellitus

(-)

Hypertension

(-)

Same

illness

(-)

Kidney

Disease

(-)

Asthma

(-)


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History of Family

Asthma-

DiabeticMelitus

-

Tuber

Culosis

-

Hyper

Tension

-

NoFamily

got

sameillness


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Medication History

The patient has never beenadmitted to hospital before

Consume certain drugs andtaking jamu pegal linu just to

get rid of the backache


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Personal and Habitual

HistoryDaily meal consumption (+)- Coffee 1 cups/day

- Sweet things : not so much

Alcohol consumption (-)

Smoking (-)

Routine Excercise (-) Rare

Tattoos (-)

Blood Transfusion (-)

Injected drugs (-)

Traditional drinks(+) 3 cups / day especiallywhen her backache attack


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General ConditionGeneral Appearance

Moderately ill

Conciousness

Compos Mentis

Height / Weight

165 / 60

BMI

22, 2 Normal


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Vital Sign

BloodPressure110/70

Heart Rate

80 x / minute

Temperature36. 5 C

Respiration24 x / minute


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Physical Examination

Head

Normocephaly

Eyes

ANEMIC CONJUCTIVA +/+ ICTERIC SCLERA -/-

Neck

Lymph Node is not palpable big

Thyroid gland is not palpable big

Mouth, Pharinx, and Nose Lip : Cyanosis (-), Pallor (-), Stomatitis (-)

Pharinx: Hiperemis (-), No secret (-)

Nose: Napas Cuping Hidung (-), Cyanosis (-)


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ThoraxINSPECTION

Ictus Cordis is Not Visible

PALPATION

Ictus Cordis is palpable at 5th ICS Midclav Sinistra

PERCUSSION

Right heart border: ICS 3-5 Sternalis Dextra

Left heart border: ICS 5 1cm medial Midclav Sinistra

Upper heart border: ICS 3 Sternalis Sinistra

AUSCULTATION

- Regular I II Heart Sound, Murmur (-), Gallop (-)


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Thorax

Inspection : Asymetrical

Supraclavicula retraction(-)

Intercostalis retraction(+)

Palpation :Equal vocal fremitus, krepitation

(+/+) Percussion :Sonor in both lung, iga and costa

feel not intact (+)

Auscultation :Vesicular breath sound in both lung

Wh -/-, Rh +/+, Friction (+)


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Abdominal Examination InspectionBrown skin, No peristaltic move seen

PalpationNo Pain on palpation at Epigastric, Hipogastric, and Suprapubic

Liver not palpableSpleen not palpable

PercussionNo pain present on abdominal percussion = TymphaniSound Dullness (-)

Shifting dullness (-)CVA (+)

AuscultationBowel sound (+) 2 times/minute. Arterial bruit (-), venous hump (-)


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Extremity Examination

+ +

+ +

WARM

ACRALS

- -

- -

OEDEM


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Laboratory Finding

Blood Results NormalHb 6.0 12-14 g/dl

Ht 18% 37-43 %

Trombosit 250.000 150.000-450.000

Leukosit 13.000 5000-10.000

ESR 10 %

Limphocytes 20 20-40 %

GDS 101 80

140 mg/dlUreum 116.5 10-45 mg/dL

Creatinin 2.61 0,4-1,5 mg/dL


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02nd August 2012

Blood Results NormalHb 9.8 (post trans 3 kolf) 12-14 g/dl

Total Protein 7,16 6-8 g/dl

Albumin 4,60 3,6 5 g/dl

Globulin 2,56 2.3 3.5 g/dl

Blood Results NormalCalcium 11.2 3-10 g/dl


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Thorax Rngten


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Rngten Schedell Ap / Lat


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Resume

HistoryTakingDifficulty of

breathing.

Headache.

Weak.

Cant moving

Pain on back.

Nausea andVomite

Cough

No defecationPh

ysicalExa

mination

Anemicconjungtiva +/+

Krepitation (+/+) Iand II ribs

Rh +/+ friction+/+

Adju

vantTest

Hb : 6,0 g %. Post:9,8

Ht : 18 %

Leukocyt : 13.000

Protein total : 7,16.

Albumin : 4, 60 mg%.

Globulin : 2,56 mg %

GDS : 101Ureum: 116,5 mg%

Creatinin :2,61 mg%

Calcium: 11,2

2


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Working Diagnosis

Anemia e.cMultiple Myeloma


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Differential DiagnosisMalignant LymphomaAcute Leukemia

Metastatic Lung Carcinoma

WaldenstromHypergammaglobulinemia

Osteomalasia


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Suggested Examination

Bone Marrow PunctureTissue Biopsy Plasmacytoma

Serum ProteinElectrophoresis


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Treatment (06 August 2012)

NON-PHARMACOLOGY

HCHP Diet

PHARMACOLOGY

- IVFD Titofusin : D5%

1 : 1 20 dpm

- Ceftriaxone 2 x 1 gr

- Azitromicin 1 x 500 mg

- Pamol 2 x 1

- Intervask 1 x 10 mg

- Furosemid 2 x 1 Inj

- KSR 1 x 1

- Valsartan 1 x 10 mg

- Dulcolac 2


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PrognosisAd

Vitam

Dubia adMalam

AdSanati

onamDubia adMalam

AdFunctionam

Dubia adMalam


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THANK YOU

Anemia Ec MM

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