JUDUL

Thalassemia with PseudothrombocytosisDr. Syahrul ChilmiPembimbing : Dr. Budiman, SpPK (K)POMR1DatabaseRGR/6 y.o. boy (Admission Date : 04/03/2014 )Chief Complaint : headacheHistory taking : patient complained headache since a day before admission, throbbing pain(+), and relieved with analgaesic drug injection. Vomited 3x/day containing phlegm and meal, but not spurt. Extremity weakness (-), sincope (-), seizure (-)Weight :16 kg, Height : 107 cm, IBW: 18kg (88%)2DatabasePast medical history:Diagnosed thalassemia for the first time in Private Hospital 4 years ago1st transfusion at age 2 years old: 2 times2nd transfusion 5 months ago: 3 times3rd transfusion recently: 4 timesFamily history: her mother often felt weak and looked pale when she got menstruation

3Physical ExaminationGeneral Condition : looked : moderately ill, GCS : 456, BP: 130/90 mmHg HR:90x/min, RR : 20x/min, Temp : 35,5C (axiler)Head & Neck : Anemic +/+, Icteric -/-, Cyan -/-Lymphadenopathy -/-Thorax :Cor : S1 S2 single, murmur (-), gallop (-)Pulmo : retraction (-), Abdomen : liver 2 cm b.a.c., splenomegaly Schoefner IVExtremity : Anemic +/+, Icteric -/-, Cyan -/-, Motoric 5/5, PhR: N/N, PR: N/N, CRT < 2, warm acral4HematologyCBC4/3Reference valueHbErythrocyteLekocyteThrombocyteHCTMCVMCHRDWReticulocyte Diff count

9,94,52 x 1066,85,06 (corrected)2169134 (corrected)27,8%61,521,9---%1,03%-/-/2/56/30/8Mielocyte: 4%, normoblast: 20/100 leukocyte11,5-16,04,0 5,0 x 1064-11 x 103142-424 x 10335,0-47,082,0-92,027,0-31,011,5-14,5%0,5-2,50-4/0-1/51-67/25/33/2-5

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HematologyBlood smear evaluationErithrocyteHypochrome microcytic, anisocytosis, poikilocytosis, spherocytes (+), teardrops (+), cigar cells (+), fragment (+++), normoblast: 20/100 leukocyteLekocyteCount and morphology normalPlateletCount and morphology normal7Clinical ChemistryTestResultReference valueAST/SGOT25 U/L0-40 U/LALT/SGPT8 U/L0-41 U/LRBG88 mg/dL