Case Leukimia

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VITYA RESANINDYA

030.08.253

SUSPECT CHRONICGRANULOCYTIC LEUKIMIA

CASEREPOR

T



Autoanamnese on 22nd of November 2012 at 13.00 pm





Name : Mrs. A

Age : 38 years

Gender : Women

Address : Karangmulya, Kec Batujaya.

Occupation : Labor

Religion : Moslem

Marital Status : Married

Race : Sundanese

Edcuation : Elementary school Taken from : Jatisari

Addmision to hospital at November 2oth 2012

IDENTITY



ANAMNESE



Patient came to Emergency Unit of Karawang Cityhospital with complaint of having pain and verydiscomfort on her left abdomen more than 2

weeks, then she also felt nausea with vomitting. Shethinks that in her left stomach filled by something like amass and becomes bigger day by day. Her appetitewas markedly less a few days ago.

Patient also complaint immense weakness withpalpitations, malaise and fatigue since 1 weeksbefore admitted to hospital. His breathing was very fastwhich was worsened by walking fast, climbing stairs,and by any kind of exertion.

HISTORY OF PRESENT DESEASE



Patient never had history of nose bleed, bruise, andswelling in both of lower extremities, but she gotbleeding gum every brush her teeth. Fever, cough,and influenza denied by her. There’s no abnormality of defecation and urination.

Patient never consume any drugs for along time.

HISTORY OF PRESENT DESEASE



HISTORY OF PAST DESEASE



FAMILY HISTORY



HABIT HISTORY



GENERAL CONDITION



VITAL SIGN





THORAX H EA R T



Inspection : Symmetrical

Palpation : Equal vocal resonance

Percussion : Sonor in both lungs

Auscultation : Vesicular breath soundin both lung, ronchi (-/-),

wheezing (-/-)

THORAX L U N G



NSPECTION Brown skin, Supple Icteric (-) ,pale (-), hematom (-), ptechie(-)

USCULTATION Bowel sound (+) normal 2x/minute, venous hum (-), Arterial bruit (-)

ERCUSSION Tymphany in all abdomen regio except hypocondrium

sinistra

ALPATION

ABDOMEN



arm acral

dema

eformation (-), brown skin , icteric (-), flapping tremor (-),

EXTREMITY

LABORATOR



Haematology Result Normal

Hemoglobin 4,0 12-17 gr/dL

Eritrocite 1,44 3.8 – 5.8 jt/mm2

Leukocytes 1100 5.000 – 10.000

Trombocytes 95.000 150.000 – 450.000

Hematocrite 14 37-43%

Diff. Count :

- Basofil 0 0-1

- Eusinofil 0 1-3

- Batang 0 2-6

- Segmen 45 40-70

- Limfosit 46 20-40

- Monosit 9 2-8

LABORATOR Y 20. 11. 2012



Result Normal

PGC 97 80-140 mg/dl

FPG 70-100 mg/dl

2-h PG <140 mg/dl

Ureum 8,6 10-45 mg/dl

Creatinin 0,58 0,4-1,5 mg/dl

Result Normal

MCV 26 82-92 mc/L

MCH 32 27-31 Pg

MCHC 13,2 32-35 %

LABORATOR



LABORATOR Y

Result Normal

Hemoglobin 6.8 12-17 g%

Leukocytes 2900 5.000 – 10.000 uL

Trombocytes 97000 150.000 – 450.000

Hematocrite 21 37-48%

Result Normal

Hemoglobin 9.9 12-17 g%

Retikulosit 19 < 2%

23. 11. 2012

25. 11. 2012



Peripheral Blood Smear



RESUME



ACUTE MIELOBLASTIK LEUKIMIA

CHRONIC LIMFOSITIC LEUKIMIA

APLASTIC ANEMIA

MYELODISPLASIA SYNDROM

NOCTURNAL PAROXISMALHEMOGLOBINURIA

DIFFERENTIAL DIAGNOSIS





Pharmacology Nacl 0,9 % 20 dpm

Khalmetazone 3x1 mg

Omeprazole 1x1 vialAminofluid 1 kolf/day

Sohobion 2x1 tab

PRC transfution 5 kolf

NonPharmacology Resting when he

need toAvoiding contactsports

Self - Protecting from

germsExercise continously,rhytmical, interval,progressive 3-4

x/day



Bone marrow biopsy

Chromosom test

Suggested examination





THANK YOU

Case Leukimia

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