CHAPTER III

CASE REPORT
Name

: RESS

Age

: 10 years

Sex

: Male

Date of Admission

: November, 23th 2012

Chief Complaint

: Swelling and pain in the scrotum

History

: This problem has already been occurring to this patient for

two days before admitted. This chief complaint happened
because the patient was felt from bicycle. This complaint was
followed by swelling in the lower pelvic region. There is sign
of hemarthrosis in left knee. The patient didnt complain any
micturation

and

defecation

disturbance.

History

of

unconciousness (-), history of fever (-), history of vomitting

and nausea (-), history of epistaxis (-). There is no history of
family that have the same symptom.
This patient has been diagnosed as Hemophilia A in 2005 by
hematology and oncology pediatric department of H. Adam
Malik General Hospital but the severity of hemophilia was not
recorded due to lost of data.
Feeding History
From birth to 6 months

: Breast milk only

From 6 months until now

: Breast milk with rice porridge

26

History of Growth and Development

Sitting

: 5 months

Crawling

:-

Standing

: 9 months

Walking

: 1 year

History of previous illness

: Hemophilia A

History of previous medications

: Koate

Family History
Father: There is no history of hemophilia
Mother: There is no history of hemophilia (Carrier)
Sister: There is no history of hemophilia

Physical Examination
Generalized status
Body weight: 22 kg, Body length: 125 cm,
Body weight in 50th percentile according to age: 31 kg
Body length in 50th percentile according to age: 137 cm
Body weight in 50th percentile according to body length: 24 kg
BW/BL: 22/24 x 100% = 91,67%
BW/age: 22/31 x 100% = 70,96%
BL/age : 125/137 x 100% = 98,42%
Presens status
Consciousness: Alert, Body temperature: 37.2oC.
Anemic (+); Icteric (-); Cyanosis (-); Edema (-). Dyspnea (-).
Localized status
27

Head :
Black hair, slightly, isochoric pupil, inferior palpebra conjunctiva pale (+/+), icteric
sclera (-/-), light reflex (+/+), ear is within normal limit, lip pale (+).
Neck :
Lymph node enlargement (-).
Thorax:
Symmetrical fusiformis, chest retraction (-). HR: 100 bpm, regular, murmur (-). RR:
24x/i, reguler, rales (-).
Abdomen:
Rapid turgor, normoperistaltic, liver and spleen unpalpable..
Extremities:
Pulse 100x/i, regular, adequate pressure and volume, warm, CRT < 3, hemarthrosis
knee.
Urogenital:
Male: swelling and bruising of the scrotum.
Laboratory Findings (November 23th 2012):
Parameters
Complete Blood Count
Hemoglobin
Hematocrite
Erithrocyte
Leucocyte
Platelet
MCV
MCH
MCHC
RDW
Difftel

Value

Normal Value

4.00 gr%
13.40 %
2,17 x 106 /mm3
12.89 x 103 /mm3
501.000 /mm3
61.80 fl
18.40 pg
29.90 gr%
18.60 %
N/B/E/L/M:

11,1 14,4 gr%

35 41%
3.71 4,25 x 106 /mm3
6.0 17.5x 103 /mm3
217.000 497.000 /mm3
82 100 fl
24 30 pg
28 32 gr%
14.9 18.7 %
37-80/0-1/1-6/2-8/20-40

54.50/0.10/0.00/10.80/4.60
Faal Hemostasis

28

Protombin Time
Control
Patient

14.00 s
19.2 s

APTT
Control
Patient

30.2 s
75.6 s

Trombin Time
Control
Patient

11.8 s
11.7 s

Normal
(10-14 s)
Normal
(25-35 s)
Normal
(14-16 s)

Laboratory Findings (November 23th 2012):

Parameters
Albumin
Blood glucose ad-random
Renal Function
Ureum
Creatinin
Electrolit
Natrium
Kalium
Chloride
Urinalisis
Colour
Glucose
Bilirubin
SG
Keton
pH
Protein
Urobilinogen
Nitrit
Blood
Urine Sedimen
Eritrosit
Leucosite
Epitel
Casts
Crystal

Value
3,8 gr/dl
123.5 mg/dl

Normal Value
3,8-54
<200

42.6 mg/dl
0.43 mg/dl

<50
0.39-0.73

134 mEq/L
4.2 mEq/L
105 mEq/L

135-155
3.6-5.5
96-106

104.20 mg/dL
Negative
Negative
1.030
Positive
5,0
Negative
Negative
Negative
Negative

Yellow
Negative
Negative
1.005-1.030
Negative
5-8
Negative

0-1
0-1
0-1
Negative
Negative

<3
<6
Negative

Negative
Negative

Laboratory Findings (November 26th 2012):

Parameters

Value

29

Factor VIII

146,0%

Differential Diagnosis:
-

Pelvic Injury + Hemophilia type A

Pelvic Injury + Von Willebrand Disease

Working Diagnosis:
Pelvic Injury + Hemophilia type A
Management:
-

IVFD RL 30 micro drops /i

Ketorolac injection 11 mg/ 6 hours/ iv
Ranitidine injection 50 mg / 12 hours/ iv
Compress and elevation

Diagnostic Planning:
-

Genu X-ray

Abdomen + Pelvic X-ray

USG Abdomen

Urology consult

30

FOLLOW UP

S
O

November, 23th 2012

Swelling and pain in the scrotum, swelling in the knee
Consciousness: alert, T: 36,8 c
o Head: conj. Palpebra inferior pale (+/+), lip pale (+/+)
o Thorax: within normal limit, HR: 120x/i. RR: 28x/i
o Abdomen: within normal limit, liver/lien unpalpable
o Pelvic: there is no fracture line, but pelvic region is reddish and
swelling
o Extrimities: hemarthrosis of knee

A
P

o Genitalia: swelling and bruising of the scrotum (+)

Hemophilia A
o IVFD Ringer Lactate 30 micro drops/i
o Inj. Ketorolac 11 mg/ 6 hours IV
o Inj. Ranitidine 50 mg/ 12 hours IV
o Inj. Koate 1000 IU/12 hours (50 mg/BW/12 hours)

31

o Dietary food 1540 kcal + 22 grams protein

o Compress and elevation foot

Consul

o There is no emergency condition in urology

o Need observation

t Result

November 24th 2012

S Swelling and pain in the scrotum, swelling in the knee
O Consciousness: alert, T: 37 c
o Head: conj. Palpebra inferior pale (+/+), lip pale (+/+)
o Thorax: within normal limit, HR: 122x/i. RR: 24x/i
o Abdomen: within normal limit, liver/lien unpalpable
o Pelvic: there is no fracture line, but pelvic region is reddish dan swelling
o Extrimities: hemarthrosis of knee
A
P

o Genitalia: swelling and bruising of the scrotum (+)

Hemophilia A
o IVFD Ringer Lactate 30 micro drops/i
o Inj. Ketorolac 11 mg/ 6 hours IV
o Inj. Ranitidine 50 mg/ 12 hours IV
o Inj. Koate 1000 IU/12 hours
o Dietary food 1540 kcal + 22 grams protein
o FFP Transfusion 3 unit
o Planning for PRC Transfusion

Transfusion needed: (11-4) x 22 x 4 = 616 cc 620 cc

Transfusion ability: 5cc/KgBb = 110 cc/ 12 jam

o Compress and elevation

32

November 25th 2012

Swelling and pain in the scrotum, swelling in the knee
Consciousness: alert, T: 36,6 c

S
O

o Head: conj. Palpebra inferior pale (+/+), lip pale (+/+)

o Thorax: within normal limit, HR: 123x/i. RR: 24x/i
o Abdomen: within normal limit, liver/lien unpalpable
o Pelvic: there is no fracture line, but pelvic region is reddish and
swelling
o Extrimities: hemarthrosis of knee
o Genitalia: swelling and bruising of the scrotum (+)
Hemophilia A
o IVFD Ringer Lactate 30 micro drops/i

A
P

o Inj. Ketorolac 11 mg/ 6 hours IV

o Inj. Ranitidine 50 mg/ 12 hours IV
o Inj. Koate 1000 IU/12 hours
o PRC transfusion 110 cc from 620 cc PRC requirement
o Dietary food 1540 kcal + 22 grams protein
Diagnosti

o Compress and elevation

o Factor VIII

c
Planning

S
O

November 26th 2012

Swelling in the scrotum, swelling in the knee is decreased
Consciousness: alert, T: 36,6 c
o Head: conj. Palpebra inferior pale (+/+), lip mucous membrane
pale (+/+)
o Thorax: within normal limit, HR: 128x/i. RR: 24x/i
o Abdomen: within normal limit
o Pelvic: Swelling and reddish are decreased
33

o Extrimities: hemarthrosis of knee

A
P

o Genitalia: swelling and bruising of the scrotum (+)

Hemophilia A
o IVFD Ringer Lactate 30 micro drops/i
o Inj. Ranitidine 50 mg/ 12 hours IV
o Inj. Koate 1000 IU/12 hours
o PRC transfusion 175 cc of 365 cc requirement
o Dietary food 1540 kcal + 22 grams protein

Lab.

o Compress and elevation

o FVIII 146 % (normal)

Resul
t
S
O

November 27th 2012

Swelling of the scrotum and swelling in the knee is decreased
Consciousness: alert, T: 36,6 c
o Head: conj. Palpabra inferior pale (+/+), lip mucous
membrane pale (+/+)
o Thorax: within normal limit, HR: 120x/i. RR: 22x/i
o Abdomen: within normal limit
o Pelvic: swelling and reddish are decreased
o Extrimities: hemarthrosis of knee

A
P

o Genitalia: swelling and bruising of the scrotum (+)

Hemophilia A
o IVFD Ringer Lactate 30 mic-drops/i
o Inj. Ranitidine 50 mg/ 12 hours IV
o Inj. Koate 1000 IU/12 hours
o Dietary food 1540 kcal + 22 grams protein

Diagnosti

o Compress and elevation

o Haemorraghic screening test

c planning

34

November 28th 2012

S Swelling of the scrotum and swelling in the knee is decreased
O Consciousness: alert, T: 36oC
o Head: conj. Palpebra inferior pale (+/+), lip mucous membrane pale
(+/+)
o Thorax: within normal limit, HR: 122x/i. RR: 23x/i
o Abdomen: within normal limit
o Pelvic: swelling is decreased
o Extrimities: hemarthrosis of knee
A
P

o Genitalia: swelling and bruising of the scrotum are decreased

Hemophilia A
o IVFD Ringer Lactate 30 micro drops/i
o Inj. Ranitidine 50 mg/ 12 hours IV
o Inj. Koate 1000 IU/12 hours
o PRC transfusion 50 cc of 315 cc requirement
o Dietary food 1540 kcal + 22 grams protein
o Compress and elevation
November 29th 2012

Home by his own request

35