SUSPECT CHRONIC GRANULOCYTIC LEUKIMIA

CASE REPOR T

VITYA RESANINDYA 030.08.253

Autoanamnese on 22nd of November 2012 at 13.00 pm

PICTUR E OF PATIEN T

IDENTITY
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

ANAMNESE

HISTORY OF PRESENT DESEASE

Patient came to Emergency Unit of Karawang City hospital with complaint of having pain and very discomfort on her left abdomen more than 2 weeks, then she also felt nausea with vomitting. She thinks that in her left stomach filled by something like a mass and becomes bigger day by day. Her appetite was markedly less a few days ago. Patient also complaint immense weakness with palpitations, malaise and fatigue since 1 weeks before admitted to hospital. His breathing was very fast which 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, and swelling in both of lower extremities, but she got bleeding gum every brush her teeth. Fever, cough, and influenza denied by her. Theres no abnormality of defecation and urination. Patient never consume any drugs for along time.

HISTORY OF PAST DESEASE

FAMILY HISTORY

HABIT HISTORY

GENERAL CONDITION

VITAL SIGN

A RT THORAX HE

THORAX
Inspection Palpation Percussion Auscultation

U NG L
: Symmetrical : Equal vocal resonance : Sonor in both lungs : Vesicular breath sound both lung, ronchi (-/-), wheezing (-/-)

in

ABDOMEN
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

EXTREMITY
arm acral

dema

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

LABORATOR Y
20. 11. 2012

Haematology
Hemoglobin Eritrocite Leukocytes Trombocytes Hematocrite Diff. Count : - Basofil - Eusinofil - Batang - Segmen - Limfosit - Monosit

Result
4,0 1,44 1100 95.000 14 0 0 0 45 46 9

Normal
12-17 gr/dL 3.8 5.8 jt/mm2 5.000 10.000 150.000 450.000 37-43% 0-1 1-3 2-6 40-70 20-40 2-8

Result
PGC FPG 2-h PG Ureum Creatinin 8,6 0,58 97

Normal
80-140 mg/dl 70-100 mg/dl <140 mg/dl 10-45 mg/dl 0,4-1,5 mg/dl

Result MCV MCH MCHC 26 32 13,2

Normal 82-92 mc/L 27-31 Pg 32-35 %

LABORATOR Y
23. 11. 2012

Result
Hemoglobin Leukocytes Trombocytes Hematocrite 6.8 2900 97000 21

Normal
12-17 g% 5.000 10.000 uL 150.000 450.000 37-48%

25. 11. 2012 Result Hemoglobin Retikulosit 9.9 19 Normal 12-17 g% < 2%

Peripheral Blood Smear

RESUME

DIFFERENTIAL DIAGNOSIS
ACUTE MIELOBLASTIK LEUKIMIA CHRONIC LIMFOSITIC LEUKIMIA APLASTIC ANEMIA MYELODISPLASIA SYNDROM NOCTURNAL PAROXISMAL HEMOGLOBINURIA

Non Pharmacology
Resting when he need to Avoiding contact sports Self - Protecting from germs Exercise continously, rhytmical, interval, progressive 3-4 x/day

Pharmacology
Nacl 0,9 % 20 dpm Khalmetazone 3x1 mg Omeprazole 1x1 vial Aminofluid 1 kolf/day Sohobion 2x1 tab PRC transfution 5 kolf

Suggested examination
Bone marrow biopsy Chromosom test

THANK YOU