MYELODySPLASTIC SYNDROME Case dr. Arif Gunawan, Sp.PD Tiara Rahmawati 030.08.240
Oct 30, 2014
MYELODySPLASTIC SYNDROME
Case dr. Arif Gunawan, Sp.PD
Tiara Rahmawati030.08.240
• Mrs. DName• 24 years oldAge • femaleSex • Adiarsa, Karawang Address
• Senior High SchoolEducation • HousewifeOccupation • IslamReligion • MarriedMarital status• July 10th 2012Admitted • Teluk JambeTaken from
IDENTITY
PICTURE OF THE PATIENT
ANAMNESIS
Autoanamnese on July 11th 2012 at 13.30
CHIEF COMPLAINT
Bleeding gums since 3 days before hospitalized
ADDITIONAL COMPLAINT
• Black and bloody excrements
• Nausea• Black vomiting• Loss of appetite
• Headache• Ptechiae in both hands and
feet• Fainting
ANAMNESIS
HISTORY OF PRESENT DISEASE
Patients came to the Emergency Unit of RSUD Karawang with complaints of gum bleeding since 3 days before hospitalized. Occurring continuously, with dark red in color. Patient denied of having a toothache.
The patient also suffers black and bloody excrements that had occurred since 3 days ago. Defecation occurred intermitten, and its excrement black in color with soft consistency and there were no phlegm detected.
Patients also suffers nausea and vomiting since 2 days before hospitalized. 2 times a day, can fill up to one aqua botol in volume, and consisted of fluid ingestion, yellow in color, with absence of blood, and without squirting. So, the patient loss her appetite.
HISTORY OF PRESENT DISEASE
On the hands and feet of patients out of red spots from 2 days before hospitalized. 1 day before hospitalized, the patient had fainted due to fatigue.
The patient denied any nosebleed, trouble breathing or coughing, and no disturbance in urination. The patient said that her menstrual cycle is once a month. Every day using a 5 pampers, no longer using pads.
APLASTIC ANEMIA (+)
was diagnosed
6 years ago
GASTRITIS
( + )
DIABETES
( - )
KIDNEY DISEASE
( - )
ASTHMA
( - )
HYPERTENTION
( - )
HISTORY OF PAST DISEASE
SAME DISEASE
( - )
HYPERTENSION
( - )
DIABETES
( - )
KIDNEY DISEASE
( - )
ASTHMA
( - )LEUKIMIA/BLOOD
DISORDER (-)
FAMILY HISTORY
• The patients received trombocyte or PRC transfusions every month
• And taking folic acid and vitamin B12 three times a day in 6 years
MEDICATION HISTORY
PERSONAL AND SOCIAL HISTORY
No consumption
of herbal drink
No smoke, no consumption of alcohol or
drugs
Seldom
exercise History of exposure to chemicals or toxic denied
General condition
General appearance • moderately ill
conciousness
• Compos mentis
Height
• 165 cm
Weight • 55 kg
BMI
• 20,2kg/m2
VITAL SIGN
Vital sign
BP:
110/50mmHg
RR
16 times/minute
HR:
80 times/minute
Temp:
36 °C
PHYSICAL EXAMINATION
• NORMOCEPHALY
HEAD
• ANEMIC CONJUCTIVA +/+• ICTERIC SCLERA -/-
EYES
• LYMPYH NODE IS NOT PALPABLE• THYROID GLAND IS NOT PALPABLE
NECK
• LIP : DRY (+), PALLOR ( + ), CYANOSIS ( - )• GUMS : BLEEDING (+)
MOUTH
THORAXHEART
INSPECTION
• Ictus cordis is invisible, spider nevi (-)
PALPATION• Ictus cordis is palpable at 5th ICS LMCS
PERCUTION• Right heart border: ICS III-V LSD• Left heart border: ICS V 1cm medial LMCS• Upper heart border: ICS III LPSS
AUSCULTATION• Regular I - II absence of murmurs and gallop in
heart’s sound
Lung Examination
THORAX
I : Symmetrical Pal : Equal vocal resonancePer : Sonor in both lungsA : Vesicular breath sound in both
lung,ronchi (-/-),wheezing (-/-)
Inspection Brown skin, distended abdomen, icteric (-), caput meducae (-)
Palpation No Pain on palpation at Epigastric Liver not palpable Spleen not palpable Shifting dullness (-)
Percussion No pain present on abdominal percussion Dullness CVA (-)
Auscultation Bowel sound (+) 2 times/minute. Arterial bruit (-), venous hum
(-)
ABDOMINAL EXAMINATION
Extremity ExaminationExtremity examination
WARM ACRALS
OEDEM
PTECHIAE
+ +
+ +
- -
- -
+ +
+ +
LABoratory findings
Test Result Normal values
Hb 5,6 (12 – 17) g%
HT 16 (37 – 48) %
Leukocyte 6200 (5000 – 10000) /ul
Trombocyte 23.000 (150.000 – 450.000) /ul
Laboratory FindingsJuly 10th 2012 Patient result Normal range
Basophil 0 0-1%
Eosinophils 0 1-3%
Band Neutrophils 0 2-6%
Segmented Neutrophils 71 40-70%
Lymphocyte 26 20-40%
Monocyte 3 2-8%
MCV 81 82-91 cu µm
MCH 29 27-31Pg/cell
MCHC 36 32-35 hb/cell
RDW 14 11,6-14,0%
Erythrocyte : Hipocrom, anisopoikilocytosis
(mikrosit, ovalosit, cigar shaped)
Leukocyte: Sufficient quantities, no pathological
shape
Thrombocyte: Decrease in total thrombocyte,
thrombocyte colony ( - ), Giant thrombocyte ( - )
Impression : thrombocytopenia with anemia
mikrositer
PERIPHERAL BLOOD SMEAR(July 10th 2012)
BONE MARROW PUNCTURE
(March 2012)
Myelodysplastic syndrome
RESUMESign & Symptoms Physical
ExaminationLaboratory and Preripheral Blood Smear
• Bleeding gums since 3 days before hospitalized
• Black and bloody excrements
• Nausea and black vomiting
• Loss of appetite• Headache• Ptechiae in both hands
and feet• Fainting
• Anemic conjuctiva
( + / + )
• Pallor and dry lips, bleeding gums
• Ptechiae on both hands and feet
Hb: 5,6 g/Dl Leukocyte : 6200Thrombocyte: 23.000 Ht : 16%
MCV :81 Hb/cellRDW:21%Diff Count Leukocyte :0/0/0/71/26/3
Peripheral blood smear:thrombocytopenia with anemia mikrositer
• MDS(Myelodisplastic Syndrome)• APLASTIC ANEMIA• ITP
DIFFERENTIAL DIAGNOSIS
WORKING DIAGNOSIS
MDS(Myelodisplastic Syndrome)
SUGGESTED EXAMINATION
KROMOSOM
LED
ESSAY FLOW CITOMETRY
THERAPY• PRC BLOOD TRANSFUSION (4 Packs)• IVFD NACL 30 drops/minute• Metil prednisolon 2x125• Dycinon 3x1• Adona /drip• Ranitidin 2x1• Ceftriaxon 2x1 gr
prognosis
Ad sanationam
dubia ad malam
Ad Fungsionam
dubia ad
malam
Ad Vitam
Dubia