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APLASTIC ANEMIA IN AN
ADOLESCENT BOY
Compiled By:
100100246
Supervisor :
APLASTIC ANEMIA
Pathophysiology
Diagnosis
Differential Diagnosis
109/L.
- Tranexamic acid is used in the dose of 2-4
g/day in 3-4 divided doses
Prevention of Infections
Treatment of Infection
MEDICAL RECORD
Name
: SA
Age
: 13 years 10 months
Sex
: Boy
Date of Admission: February, 1st 2014
Feeding History
From birth to 6 months : Breast milk only
From 6 months to 9 months: Breast milk with rice porridge
From 9 months to 1,5 years: Breast milk with soft rice
From 1,5 years until now: Family food
Physical Examination
Generalized status
Body weight: 30,5 kg, Body length: 133 cm,
Body weight in 50th percentile according to age: 50 kg
Body length in 50th percentile according to age: 162 cm
Body weight in 50th percentile according to body length: 38 kg
BW/BL: 30,5/38 x 100% = 107%
BW/age: 30,5/50 x 100% = 92,4%
BL/age : 133/162 x 100% = 86,36%
Presens status
Consciousness: GCS 15 (E4 V5 M6)
Blood Pressure: 100/60 mmHg
Heart Rate: 88 x/i
Respiratory Rate: 20 x/I
Body Temperature: 36,5oC.
Anemic (+). Icteric (-). Cyanosis (-). Edema (-). Dyspnea (-)
Differential Diagnosis:
Aplastic Anemia
Acute Lymfositic Leukemia (ALL)
Working Diagnosis:
Aplastic Anemia
Management :
O2 1-2 L/i
IVFD D5% NaCl 0,45% 10 gtt/i micro
Blood transfusion
PRC : (11 9,2) x 4 x 30 = 216 cc (1 bag @175cc)
Diagnostic Planning
Laboratory
Findings:
January, 31st
2014
FOLLOW UP
February, 2nd February, 11th 2014
S : pale (+)
O: Cons: alert, Temp: 36,7oC. Anemic (+). Icteric (-).
Edema (+). Cyanosis (-). Body weight: 30,5 kg, Body
length: 133 cm.
Mouth : pale mucosa (+), bleeding gums found with
volume a little bit. Hematomas found on the regio volar
forearm left and right with size 2x2cm. Ptekie found on
the leg, upper arm, and forearm left and right.
A: Aplastic Anemia
Management:
IVFD D5% NaCl 0,45% 10 gtt/i micro
Oral prednisone 4-3-3
Folic acid 1x1 mg
DISCUSSION
Theory
Case
Physical Examination :
Thrombocytopenia manifests with
petechiae, ecchymoses, epistaxis,
gum bleeding and menorrhagia
DISCUSSION
Theory
Case
Summary
It has been reported, an adolescent boy with the main
complain of pale and was diagnosed with anemia aplastic. The
diagnose was established based on history taking, clinical
manifestation, laboratory finding, and bone marrow puncture.
The patient got PRC transfusion and still need to be followed up
Thank You