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MORNING REPORT

FRIDAY, 10TH NOVEMBER 2017

dr. Fitri/ dr. Aya / dr. Dian/ dr. Galih/ dr.Tatag


dr. Pitra / dr. Ahimsa
dr. Dhimas/ dr. Mitha

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PATIENT ADMISSION

MELATI 2 WARD
A, male, 11 months old, 6 kgs, with acute diarrhea with severe
dehidration, post ileostomy due to intussusception, wasted.
A, male, 3 years old, 11 kgs with suspected acute ITP, microcytic
hipochromic anemia due to iron deficiency dd chronic infection,
wasted.
D, 2 months old, 4 kgs, with suspected acyanotic congenital heart disease,
VSD dd ASD dd PDA, Ross III, wellnourished.
NEONATAL HCU: -
PICU : -
MELATI 2 HCU : -
NICU : -
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PATIENT IDENTITY

Name :A
Sex : male
Age : 3 years old
Body weight / height : 11 kgs / 97 cm
Adress : Pulorejo, Wonogiri
Medical Record : 01398312

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CHIEF COMPLAINT

Bruises
(referred from PKU Solo)

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CURRENT MEDICAL HISTORY

7 days before 3 days before At ER


admission admission Patient was fully
Patient got sudden Patient still had bruises alert, there were
bruises on both on his cheek, arms, legs some bruises on his
legs, body and right and body arms and legs,
arm, history of Gum bleeding (-), No fever, no gum
trauma (-) nosebleed(-), no fever bleeding or
Patient look pale nor cough nosebleed, no
No nose bleed, no His parents brought headache
gum bleeding, no him to private hospital Defecation and
fever, cough, vomit, perform laboratory urination within
Eat and drink examination result normal limit
within normal limit was very low platelet
No complaint count (7000/ml)
about urination got 3 unit transfussion
and defecation of platelet reffered
to Moewardi hospital

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PAST MEDICAL HISTORY

History of hospitalization (-)


History of same illness (-)
History of skin and respiratory tract infection (+) in recent
2 months

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FAMILY MEDICAL HISTORY

History of hematology disorder in family was denied


History of same illness in family(-)

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PREGNANCY AND DELIVERY HISTORY

During pregnancy, his mother routinely checked up her pregnancy


to obstetrician. She was given vitamin, and she didnt consume any
medicine beside it. She hasnt got hospitalized during pregnancy and
has no fever, no hypertension
Baby boy was born in 39 weeks of pregnancy by spontaneous
delivery. he cried vigorously, no cyanosis or jaundice. His birth
weight was 2900 grams, 48 centimeters in length, meconeum was
found

Conclusion: Pregnancy and delivery history were normal

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VACCINATION HISTORY

BCG : 1 month
Hepatitis B0 : 0, 2,3,4 months
DPT-HB-HiB : 2,3,4 months
Polio : 2,3,4 months
measles : 9, 18 months

Conclusion :
complete immunization,
appropriate with Ministry of Health schedule 2014
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NUTRITION HISTORY

Patient eat rice, chicken, bef, fish, fruit and some of vegetables. His
portion usually - adult portion. He also drink milk sometimes
Conclusion: quantity and quality were adequate

GROWTH AND DEVELOPMENT


He is 3 years old now,11 kgs in body weight, 92 cm in lenght.
Birth weight : 2900 gram
He can play with his friends, communicate well, he can say 3
word and form a sentences.
Conclusion: appropriate for his age 10
NUTRITIONAL STATUS

Weight for Age: Weight/Age = -2 SD


Underweight
Height for Age: -2 SD< Height/Age < 0 SD
Normoweight
Weight for Height : -3 SD< Weight/ Height < -2 SD
Wasted
Conclusion:
Underweight, Normoheight, Wasted (WHO)
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FAMILY TREE

II

III

A, 3 years old 12
PHYSICAL EXAMINATION

General appearance :fully alert, GCS E4M6V5


Vital sign :
Heart Rate = 118 bpm
Respiration rate = 24 bpm
Temperature = 36.6 0 C peraxilar
O2 saturation = 98%
Blood pressure = 100/60 mmHg

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Head : mesocephal,, hematom (+)right frontal region
Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex (+/+),
isochoric pupil 3 mm/3mm, sunken eyes (-/-), tears (+/+)
Nose : nasal flare (-/-), discharge (-/-), nosebleed(-/-)
Mouth : wet lips (+), lips and tongue not cyanotic, cleft lip palate (-), gum bleeding(-/-)
Throat : hyperemic pharing (-),Tonsil T1-T1 hyperemic (-), detritus (-)
Neck : Enlargement of lymph node (-)
Thorax : symmetric (+), retraction (-)

LUNG:
I: normal, symmetric, retraction (-)
P: fremitus difficult to evaluation
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (-/-)

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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I: abdominal wall equal to chest wall, hernia umbilicalis (-)
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery
was strongly palpable, multiple hematom on extremities.
GENITALIA : , phimosis (-) 15
LABORATORY FINDINGS

Hb : 10.2 g/dl
HCT : 32%
AL : 11.7 thousand/ul Conclusion :
AT : 38 thousand/ ul
- Thrombocytopenia
AE : 4.17 mil/ul
- Anemia microcytic
MCV: 76.0 /um
hipochromic
MCH : 24.5 pg
Netrophyl : 75.40 %
Limphocyte : 20.10 %

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LISTS OF PROBLEM

A,3 years old, 11kgs with :


Sudden Bruises on both arms legs, and face,
History of trauma (-)
No gum bleeding, no nose bleed, no fever, no cough,
Thrombocytopenia
Microcytic hipochromic anemia

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DIFFERENTIAL DIAGNOSIS

1. Suspected acute immune thrombocytopenic purpura


2. Microcytic hipochromic anemia due to iron deficiency dd
with chronic infection
3. Wasted

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WORKING DIAGNOSIS

1. Suspected acute immune thrombocytopenic purpura


2. Microcytic hipochromic anemia due to iron deficiency dd
with chronic infection
3. Wasted

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THERAPIES

Admitted to pediatric hematology ward


Nutrition rice pack diet 1500 kkal / day
IVFD D NS 40 ml/hour
Metil prednisolone (4 mg/kgBW/day) 50 mg/24 hour I.V.

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PLAN
1. Peripheral blood smear examination
2. SI, TIBC, serum feritin, transferin saturation
examination
3. Three unit of Platelet transfussion if there is
spontaneous bleeding

MONITORING

General appearance / vital signs / oxygen


saturation every 8 hours
Blood glucose every 24 hours
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FOLLOW UP 11TH NOVEMBER 2017

S : bruise (+) no fever, no vomit, no nausea, cough (+),


regularly, defecation +
General appearance : fully alert
Vital sign :
Heart Rate = 110 bpm
Respiration rate = 22 bpm
Temperature = 36.9 (36.6-37.30 C )peraxilar
O2 saturation = 98% 22
Head : mesocephal,, hematom (+)right frontal region
Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex (+/+),
isochoric pupil 3 mm/3mm, sunken eyes (-/-), tears (+/+)
Nose : nasal flare (-/-), discharge (-/-), nosebleed(-/-)
Mouth : wet lips (+), lips and tongue not cyanotic, cleft lip palate (-), gum bleeding(-/-)
Throat : hyperemic pharing (-),Tonsil T1-T1 hyperemic (-), detritus (-)
Neck : Enlargement of lymph node (-)
Thorax : symmetric (+), retraction (-)

LUNG:
I: normal, symmetric, retraction (-)
P: fremitus difficult to evaluation
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (-/-)

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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I: abdominal wall equal to chest wall, hernia umbilicalis (-)
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery
was strongly palpable, multiple hematom on extremities.
GENITALIA : , phimosis (-) 24
DIAGNOSIS

1. Suspected acute immune thrombocytopenic purpura


2. Microcytic hipochromic anemia due to iron deficiency dd
with chronic infection
3. Wasted

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THERAPIES

Admitted to pediatric hematology ward


Nutrition rice pack diet 1500 kkal / day
IVFD D NS 40 ml/hour
Metil prednisolone (4 mg/kgBW/day) 50 mg/24 hour I.V.

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PLAN
1. Peripheral blood smear examination
2. SI, TIBC, feritin serum, transferin saturation
examination
3. Three unit of Platelet transfussion if there is
spontaneous bleeding

MONITORING

General appearance / vital signs / oxygen


saturation every 8 hours
Blood glucose every 24 hours
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Bantis Syndrome
Synonyms of Bantis Syndrome
Banti's Disease
Hypersplenism
Idiopathic congestive splenomegaly
Idiopathic portal hypertension
General Discussion
Banti syndrome is a disorder of the spleen, the large, gland-like organ in the upper left side of the abdomen that
produces red blood cells before birth and, in newborns, removes and destroys aged red blood cells, and plays a
role in fighting infection. In the case of Banti syndrome, the spleen rapidly but prematurely destroys blood cells.
This syndrome is characterized by abnormal enlargement of the spleen (splenomegaly) due to obstruction of
blood flow in some veins and abnormally increased blood pressure (hypertension) within the veins of the liver
(e.g., hepatic or portal veins), or the spleen (splenic veins). The disorder may be due to any number of different
factors causing obstruction of portal, hepatic, or splenic veins including abnormalities present at birth
(congenital) of such veins, blood clots, or various underlying disorders causing inflammation and obstruction of
veins (vascular obstruction) of the liver.

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