SUMMARY OF DATA BASE

Mr Ananda/22yo/W.25 (Autoanamnesis)
Chief complain : Pain in left knee
Patient suffered from pain in his left knee since a day before
admission. The pain was getting worse when patient moved or walked,
stiffness < 15 minutes. The pain was on and off since a year ago. Sometimes
pain was inflamed and swelling, accompanied low grade fever, getting better
with consumption meloxicam and methylprednisolon from internist.
He also suffered decrease of appetite, ate 1-2x per day, porridge, a
half portion since a month ago. His body weight decrease 5 kg in a month,
his passing urine decrease and passing stool were normal limit.
He was diagnosed hemophilia since 20 years ago, routine Factor VIII
injection at RSSA or RS Kepanjen since 3 years ago.
He was disgnosed Epileptic since 2 years ago, he routine consumed
fenitoin 2x100mg since 2 years ago.
Past Medical History:

He did’nt have history of Diabetes Mellitus nor Hypertension before.

Family history: her brother has hemophilia and passed away at 6 years old

Social and environmental history:

Not yet Married, assistant mechanical engineer, he smoked since youth until
now about 4bars/day, there were history of consumed traditional potion to
increase his appetite since 5 years ago and consumed NSAID since a year ago to
relieve the pain.
 PHYSICAL EXAMINATION
General appearance looked moderatelyillness Looked normoweight
GCS 456
BP= 120/70 mmHG PR = 82 bpm,regular, strong RR= 20 tpm Tax= 37.10C

Head ConjuctivaAnemic (-- ) Pupil isocor (+) 3/3 mm

Sclera Icteric (-) cyanosis (-) edema (-)
Neck JVP R + 0cm H20, 300 position
Lnn. Enlargement (-)

Thorax Ictus invisible & palpable at ICS V MCLS,

Heart RHM ~PSL D, LHM ~ ictus, S1 S2 single regular, murmur (–)
Lung Symetric Stem fremitusD=S Sonor + + vv Rh - - Wh - -

++ vv - - - -

++ vv - - - -

Abdomen Soefl, Bowel Sound (+) N, Liver span 8 cm, traube’s space tymphani, shifting
dullness
Extremitiey Edema - - Warm acral Genue Sinistra : pain, edema, warm, decrease ROM
- +
 LABORATORY FINDINGS
Lab Value Lab Value
Leucocyte 9250 4000-11.000/µL Na 128 136-145mmol/l
Diff count 0.1/0.2/81. 0-4/0-1/51-67/25- K 4.13 3,5-5,0 mmol/l
7/12.1/5.9 33/2-5 %
Haemoglobin 14.7 11-16,5 g/dL Cl 103 98-106 mmol/l

MCV 86.10 80-93 fl RBS 131 < 200 mg/dL

MCH 29.50 27-31pg Ureum 14.50 16,6-48,5 mg/dL

PCV 42.90 40-47 % Creatinin 0.67 < 1,2 mg/dL

Thrombocyte 214000 150-450x103/µL Lactic acid 2.4 0.5-2.2

SGOT/AST 36 11-41U/L Factor VIII 1,25 100%
SGPT/ALT 27 11-41U/L
PPT 13.90 (11.1)
APTT 103.20 (28.9)
INR 1.19 0.8-1.30
ECG
 ECG

 Sinus rhytm, Heart rate 93 bpm

 Frontal Axis :N
 Horizontal Axis :N
 PR interval : 0,12”
 QRS complex : 0,08”
 QT interval : 0,36”

Conclusion : Sinus rhytm, Heart rate 93 bpm

CXR
 Chest X-Ray

 AP position, asymmetrical, KV enough, enough inspiration

 Soft tissue normal, Bone normal
 Trachea in the middle
 Hemidiaphragm D /S is dome shape
 Phrenico cotalis angle D/S is sharp
 Pulmo D/S :BVP N
 Cor site N, size : CTR 49 %, Shape N
 Conclusion :Normal CXR
Genu AP/Lat Sinistra X-Ray
 Genu AP/Lat Sinistra X-Ray

 Soft tissue swelling at genue S

 Bone : trebeculae porotic at condylus mediolateral os femur S
 Joint space narrowed at genue S
 Conclusion: knee radioopaque efusion at joint space
Cue and Clue Problem Initial Planning Planning Teraphy Planning
List Diagnosa Diagnosa Monitoring &
Education
Male/22yo/w25 1. Acute Dt Bleeding -Rest, Ice, Compression, Elevation S
•Pain , swelling in hemarthr hemophilia time - Diet High Calory High Protein VS
knee S osis Clotting 2100 Kcal/day Bleeding
•Has hemophilia, Sinistra time -IVFD NS 20 dpm
routine controlled, -Ibuprofen 3x400 mg po P Edu: Disease,
routine factor VIII -Codein 3x10 mg po risk factor,
injection management
PE
GCS 456
• BP 120/70 mmHg
•PR 82 x/min, strong
regular
• RR 20 x/min
• Tax 37,1
•Genue Sinistra : pain,
edema, warm, decrease
ROM
LAB
• Hb: 14.7
•Trombocyte 214000
• PVC 42.90
•PPT: 13.90
• APTT : 103.2
•INR : 1.19
•Factor VIII 1.25%
•Lactic acid 2.4
Genu AP/Lat Sinistra :
knee radioopaque
Cue and Clue Problem Initial Planning Planning Teraphy Planning
List Diagnosa Diagnosa Monitoring &
Education
Male/22yo/w25 2. Bleeding -Bedrest S
•Has hemophilia, Hemop time - Diet High Calory High VS
routine controlled, hilia A clotting Protein 2100 Kcal/day Bleeding
routine factor VIII
-IVFD NS 20 dpm
injection
-Tranfusion FFP P Edu:
•History of Disease, risk
prolong bleeding 10cc/KgBW/day
-Injection Factor VIII 1750 factor,
since he was child
PE IU IV management
GCS 456
• BP 120/70 mmHg
•PR 82 x/min,
strong regular
•Tax 37,1
LAB
• Hb: 14.7
•Trombocyte
214000
• PVC 42.90
•PPT: 13.90
• APTT : 103.2
•INR : 1.19
•Factor VIII 1.25%
Cue and Clue Problem Initial Planning Planning Teraphy Planning
List Diagnosa Diagnosa Monitoring &
Education
Male/22yo/w25 3. -Bedrest S
•Has epileptic Epilepti - Diet High Calory High VS
since 2 years ago c on Protein 2100 Kcal/day Seizure
on routine treatme
-Phenitoin 2x100mg po
consumed fenitoin nt P Edu:
PE Disease, risk
GCS 456
factor,
• BP 120/70 mmHg
•PR 82 x/min, management
strong regular
•Tax 37,1