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lapsus

1. Dasrul , male, 41 y.o IW 9 1 Chief Complaint Fever since 4 days ago Present Illness History Fever since 4 days ago not high, no chills, occasionally excessive sweating. The body feels weak and fatigued since a week ago. No cough, runny nose, or shortness of breath. No nausea or vomiting. Bowel and urinary functions are normal. No nosebleeds or gum bleeding, no blood in urine or stool. The patient was recently diagnosed with AML M4 based on bone marrow biopsy results in November and is scheduled for chemotherapy.

2. Past Illness History History of DM (-) History of HT (-) History of CKD (-)

3. VII General Appearance: moderate Consciousness level : CMC BP : 130/80 mmHg H R : 80 x/minute, reguler R R : 20 x/minute T : 38,5 C Spo2 : 98% free air Physical Examination

4. VII Eye C onjunctiva anemic (+) Icteric sclera (-) JVP 5-2 cmh20 Lung Inspection : static ally & dynamic ally symmetric Palpation : fremitus normal Percussion : Sonor Auscultation : vesicular, Rh -/-, Wh -/-

5. VII Cor : Inspection : ictus is not seen. Palpation : ictus is palpated at LMCS RIC V Percussion : Left border : LMCS ICS V Right border : linea parasternalis dextra Upper border: ICS II Auscultation : regular, murmur ( + )

6. VII Abdomen: Inspection: distension (-) Palpation: Hepar lien not palpable, tenderness (-) Percussion: tympani Auscultation: bowel sound (+) Extremities: warm, edem -/-

7. VII Items Value Hb 4,2 Ht 13 Leukosit 48210 Platelet 8.000 electrolyte 141/3,5/107 Ur/ cr 24/1,2 blood glucose 112 Laboratory 12/12

8. VII ECG

9. Rontgen Thorax

10. Problems - Fever Fatique and weakness Murmur+ anemia Trhombocitopenia

11. Working Diagnosis Acute My eloblastic L eucemia M4 Moderate Anemia normositic normochrom ec susp infiltration of leukemic cell Trombocitopenia cb susp infiltration of leukemic cell Anemia Heart disease

12. Therapy Rest, high-calorie high-protein diet (MB TKTP), IVFD NaCl 0.9% at kolf /8 hours, Paracetamol 3x500 mg Folic acid 1x1 mg B complex 2x1 tablet transfusion of 2 units of PRC /day transfusion of 5 units of TC /day

13. Plan Check DPL transfussion chemotherapy