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    SCENARIOSCENARIO

    A girl aged 5 years old, wasA girl aged 5 years old, was

    brought to the hospital becausebrought to the hospital because

    she got red spots on her arm,she got red spots on her arm,

    lower extremities and abdomen,lower extremities and abdomen,

    blood coming out rom her anusblood coming out rom her anus

    with no e!er" # days ago, she hadwith no e!er" # days ago, she had

    $ust reco!ered rom cough with$ust reco!ered rom cough withrhinorrhea"rhinorrhea"

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    %E&'OR(S%E&'OR(S

    girl aged 5 years oldgirl aged 5 years old red spots on her arm, lower extremitiesred spots on her arm, lower extremities

    and abdomenand abdomen

    blood coming out from her anusblood coming out from her anus no feverno fever

    Previous cough and rhinorrhea, 6 daysPrevious cough and rhinorrhea, 6 days

    ago.ago.

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    )ER*S C+ARIICA)ION)ER*S C+ARIICA)ION

    Hemorrhage:the escape blood from the vessel.Hemorrhage:the escape blood from the vessel.

    Petechia : a red spot due to escape of a small of blood.Petechia : a red spot due to escape of a small of blood.

    Purpura : a small hemorrage in the sin,mucousPurpura : a small hemorrage in the sin,mucous

    membrane, ormembrane, or serous surface. serous surface.

    !cchymoses:a small hemorrhagic spot in the sin or a!cchymoses:a small hemorrhagic spot in the sin or amucousmucous membrane, larger than a petechia,membrane, larger than a petechia,

    forming aforming a nonelevated, rounded, or irregularnonelevated, rounded, or irregular

    blue or purplishblue or purplish patch. patch.

    "elena"elena : the passage of dar stools stained with: the passage of dar stools stained with

    altered blood byaltered blood by the intestinal #uices. the intestinal #uices.Hematoche$ia : the passage of red bloody stoolsHematoche$ia : the passage of red bloody stools

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    -.ES)IONS-.ES)IONS

    How is the mechanism ofHow is the mechanism of

    hemostasis%hemostasis%

    How hemmorhage or bleeding canHow hemmorhage or bleeding canoccur%occur%

    &hat is the correlation of previous&hat is the correlation of previous

    disease with the symptom%disease with the symptom% 'i(erential diagnosis and their'i(erential diagnosis and their

    description.description.

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    HEMOSTASIS

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    BLOOD COAGULATION

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    I/RINO+&SIS 0I/RINO+&SIS 0

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    FIBRINOLISIS 2

    XIIa

    INTRINSIK

    KALIKREIN

    PLASMINOGEN

    EKSTRINSIK EKSOGEN

    AKTIVATOR

    PLASMINOGEN

    UROKINASE

    TERIKAT

    PLASMIN

    TERIKAT FIBRIN

    FDP

    PLASMINOGEN

    BEBAS

    BEBAS

    PLASMINFIBRINNOGEN

    F V

    F VIII

    ANTI PLASMIN

    t-PA

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    1E*ORR1A2E31E*ORR1A2E3

    )ascular abnormality)ascular abnormality

    *hrombocyte abnormality*hrombocyte abnormality

    +oagulation abnormality+oagulation abnormality 'eciency vitamin -'eciency vitamin -

    *rauma*rauma

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    (IEREN)IA+(IEREN)IA+

    (IA2NOSIS(IA2NOSIS 'isseminated ntravasucular'isseminated ntravasucular+oagulation+oagulation

    diophatic *hrombocytopenicdiophatic *hrombocytopenic

    PurpuraPurpura

    Henoch /choenlein /yndromeHenoch /choenlein /yndrome

    von &illebrand 'iseasevon &illebrand 'isease Hemophilia 0Hemophilia 0

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    )A/+E)A/+E

    '+'+ *P*P H!12+HH!12+H/+H2!13/+H2!13!1!1/41'2"!/41'2"!

    )21!&33)21!&33!01'!01'/41'2"!/41'2"!

    H!"2PH30H!"2PH3000

    P!*!+H0P!*!+H0 77 77 77 77

    8P9P908P9P90

    ;;

    H!"0*2+H!

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    (ISSE*INA)E((ISSE*INA)E(IN)RA4ASC.+ARIN)RA4ASC.+AR

    COA2.+A)IONCOA2.+A)ION

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    DefnitionDefnition

    Disseminated intravascular coagulation (DIC) is a

    complex systemic thrombohemorrhagic disorder

    involving the generation of intravascular fibrin

    and the consumption of procoagulants and

    platelets.

    DIC is a syndrome arising as a complication ofmany different serious and life-threatening

    illnesses.

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    CON)CON)

    /ynonim: +onsumption coagulopathy ,/ynonim: +onsumption coagulopathy ,

    Hiperbrinolytic activation,Hiperbrinolytic activation,debrination anddebrination and

    thrombohemorragic disorderthrombohemorragic disorder

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    ET IOLOGYET IOLOGY 2bstretical complication:2bstretical complication:

    ; abruptio placentae; abruptio placentae

    ; amniotic Auid embolism; amniotic Auid embolism

    ; dead fetus syndrome; dead fetus syndrome

    ;; Septic abortionSeptic abortion *rauma : ; burns*rauma : ; burns nfection: ; bacteria /epsisnfection: ; bacteria /epsis

    ; viral viremia; viral viremia mmunologic B lood transfusion mistaemmunologic B lood transfusion mistae "alignancy, example : 3euemia"alignancy, example : 3euemia

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    PATOMECANISPATOMECANIS

    MMPrecipitating "echanismPrecipitating "echanism

    *issue damage !ndothelial*issue damage !ndothelial

    damagedamage

    *issue tromboplastin /timulate*issue tromboplastin /timulate

    intrinsicintrinsic

    8> pathway of8> pathway of

    coagulationcoagulation

    !xtrinsic pathway of 8>. C from blood!xtrinsic pathway of 8>. C from blood

    plasmaplasma

    +oagulation protein+oagulation protein

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    'isseminated'isseminated

    +oagulation process+oagulation process

    2cclusion ntravascular trombin; brin DD2cclusion ntravascular trombin; brin DD+onsumption+onsumption

    blood vessel ; +oagulationblood vessel ; +oagulationfactorfactor

    ; platelet.; platelet.

    *issue ischemic >ibrinolysis DD8Homeostasis*issue ischemic >ibrinolysis DD8Homeostasis

    =organs 777=organs 777

    educe:educe: >'P ; +oagulation factor>'P ; +oagulation factor

    ; platelet; platelet

    1ecrosis1ecrosis

    coagulation inhibitedcoagulation inhibited

    leedingleeding

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    CLINICALCLINICAL

    SYMPTOMSSYMPTOMS'+ BD *rombosis and bleeding can be happen together'+ BD *rombosis and bleeding can be happen togetherE. Hemorrhagic diatesis : leeding preference.E. Hemorrhagic diatesis : leeding preference.

    ; 'ermatology : Petechiae, ecchymosis of sin or; 'ermatology : Petechiae, ecchymosis of sin ormucous membranemucous membrane

    nger ganggrenous.nger ganggrenous. ; ?astro : Hematemesis, hematoche$ia, and visceral; ?astro : Hematemesis, hematoche$ia, and visceral

    hemorrhagehemorrhage

    ; ?enitourinary : Hematuria, metrorrhagia.; ?enitourinary : Hematuria, metrorrhagia.

    ; ?inggival bleeding.; ?inggival bleeding.

    F. 'ispneuF. 'ispneu

    G.G. tachycardia, tachypnea, and hypotensiontachycardia, tachypnea, and hypotension5.5. In severe cases, patients may develop feverIn severe cases, patients may develop fever

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    LABORATORY FINDINGLABORATORY FINDING

    lood sho!s an abnormalities coagulation because of fibrinogenlood sho!s an abnormalities coagulation because of fibrinogen

    deficiency.deficiency.

    "emostatic #xamination $"emostatic #xamination $

    %. &latelet count decreased%. &latelet count decreased'. Decreased fibrinogen level'. Decreased fibrinogen level

    . &rolonged prothrombin time, activated partial. &rolonged prothrombin time, activated partial

    thromboplastin time, thrombin timethromboplastin time, thrombin time

    . Increased levels of *D& ( on testing for *D&, D-dimer). Increased levels of *D& ( on testing for *D&, D-dimer)

    +. Schistocytes on peripheral smear+. Schistocytes on peripheral smear

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    TREATMENTTREATMENT%. Individual treatment%. Individual treatment

    - reatment closely !ith the etiology, ages, and hemodinamic situation.- reatment closely !ith the etiology, ages, and hemodinamic situation.

    - Determine the underlying cause of the patients DIC and initiate- Determine the underlying cause of the patients DIC and initiatetherapytherapy

    '. eneral$'. eneral$

    a.a. /onitor vital signs and attend to life-threatening issues such as air!ay/onitor vital signs and attend to life-threatening issues such as air!ay compromisecompromise

    b. Stop the coagulation $b. Stop the coagulation $

    #xp$ "eparin, give if $#xp$ "eparin, give if $

    - &rimary disease can0t be stop 1uic2ly- &rimary disease can0t be stop 1uic2ly

    - 3ith ischemia or thromboembolism- 3ith ischemia or thromboembolism c. Substitution treatmentc. Substitution treatment

    transfusions of fresh fro4en plasma or platelet.transfusions of fresh fro4en plasma or platelet.

    d. 5sam trane2samat as antifibrinolysis if indicatedd. 5sam trane2samat as antifibrinolysis if indicated

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    Henoch SchoeleinHenoch Schoelein

    Syndo!eSyndo!e

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    1enoch 6 Scholein1enoch 6 Scholein

    SyndromeSyndrome0n abnormal inAamation process0n abnormal inAamation processthat involve a peripheral vasulerthat involve a peripheral vasulerwall especially at sin, digestivuswall especially at sin, digestivus

    trac, idney and #oints.trac, idney and #oints. nsidens :nsidens :

    +hildren, F I years old+hildren, F I years old

    "ale : >emale B F : E"ale : >emale B F : E "ore incidence happen at the spring"ore incidence happen at the spring

    and winterand winter

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    EtiologyEtiology

    diopatidiopati

    mmune reaction g0mmune reaction g0

    nfection )irus or baterianfection )irus or bateria HerediterHerediter

    'rugs allergy'rugs allergy

    nsect bittingnsect bitting >ood>ood

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    Clinical *aniestationClinical *aniestation

    ash Purpura 8ex : Petechiae ash Purpura 8ex : Petechiae

    0bdominal pain0bdominal pain

    Poliatralgia 7 Joint swellingPoliatralgia 7 Joint swelling ?astrointestinal bleeding?astrointestinal bleeding

    enal = -idney 'iseaseenal = -idney 'isease

    +1/ manifestation+1/ manifestation

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    7atomechanism7atomechanism

    !tiology of H//!tiology of H//

    ncreased production of g0ncreased production of g0

    g0 spreading out and gathered at theg0 spreading out and gathered at theperipehral vasuler wallperipehral vasuler wall

    'isturbing and 0ltering the vasular'isturbing and 0ltering the vasularendotel cell main functionendotel cell main function

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    7atomechanism7atomechanism

    !ndotel cell stimulates chemical mediator,!ndotel cell stimulates chemical mediator,

    such as *1> alfa and 3 Isuch as *1> alfa and 3 I

    ncreased of an abnormal apoptosis ofncreased of an abnormal apoptosis ofendotelial cellendotelial cell

    1eutrol and limfosit inltration1eutrol and limfosit inltration

    nAamationnAamation

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    Supporti!e )estSupporti!e )est

    3aboratorium :3aboratorium : +omplete lood +ount 3euocytosis+omplete lood +ount 3euocytosis

    9rinalysis Hematuria 7 proteinuria9rinalysis Hematuria 7 proteinuria

    g0 serum level increasedg0 serum level increased /in iopsy 3euocytoclastic vasulitis/in iopsy 3euocytoclastic vasulitis

    adiographyadiography

    +hest and abdominal maging+hest and abdominal maging

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    )herapy)herapy

    ed rest 7 /upportive careed rest 7 /upportive care

    /elf 3imiting disease/elf 3imiting disease

    8resolve in 6 I wees8resolve in 6 I wees

    mmunosuppresan +yclophosphamidemmunosuppresan +yclophosphamide

    +orticosteroid+orticosteroid

    1/0' 81on /teroid 0nti nAamation 'rugs1/0' 81on /teroid 0nti nAamation 'rugs; 'apsone'apsone

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    IdiopathicIdiopathic

    )rombocytopenic)rombocytopenic7urpura7urpura

    8I)798I)79leeding, petechie = eimosis onleeding, petechie = eimosis onthe sin or mucous membranethe sin or mucous membrane

    with trombocyte reduction whichwith trombocyte reduction whichis usually idiopathic.is usually idiopathic.

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    Classi:cationClassi:cation

    0cute0cute : children F;I years old,: children F;I years old,

    I5 KLMI5 KLM

    +hronic+hronic : adults E5;5L years: adults E5;5L years

    old, EL E5Mold, EL E5M

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    Acute I)7Acute I)7

    ncidence ;D age : F I years oldncidence ;D age : F I years old

    >emale D "ale B N : G or F : E>emale D "ale B N : G or F : E

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    7atomechanism7atomechanism

    0utoantibody g? binding on the platelet surface0utoantibody g? binding on the platelet surface

    Platelet sensitatedPlatelet sensitated

    "acrofage !/ fagocytosis"acrofage !/ fagocytosis

    8 in hepar and spleen8 in hepar and spleen

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    Signs and SymptomsSigns and Symptoms

    leeding ;D sin and mucousleeding ;D sin and mucousmembrane 8petechie, melena,membrane 8petechie, melena,epitasis, hematuri, cerebralepitasis, hematuri, cerebral

    bleeding at severe trombocytopeni.bleeding at severe trombocytopeni. *iredness, weight loss, limph gland*iredness, weight loss, limph gland

    enlargementenlargement

    >eeling of saturated stomach,>eeling of saturated stomach,stomach painstomach pain

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    )ests and Examinations)ests and Examinations

    Peripheral blood test B trombocytopenia,Peripheral blood test B trombocytopenia,normocytic, normal leucocyte andnormocytic, normal leucocyte andascending on heavy bleedingascending on heavy bleeding

    one marrow test B commonly normal,one marrow test B commonly normal,increasing of megaariocyteincreasing of megaariocyte

    eduction of coagulation retractioneduction of coagulation retraction

    !xtended bleeding time!xtended bleeding time

    /horter P+*/horter P+*

    *urniet *est 87*urniet *est 87

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    )reatment)reatment

    /ome patients ;D /pontaneous/ome patients ;D /pontaneous

    remisionremision

    /evere ;D corticosteroid/evere ;D corticosteroid

    ntravenous heparinntravenous heparin

    *ransfusion of trombocyte*ransfusion of trombocyte

    suspensionsuspension

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    EthiologyEthiology

    diopathicdiopathic

    Hipersplenism, viral infection, food,Hipersplenism, viral infection, food,

    'rugs : asetosal, paraaminosalisilat,'rugs : asetosal, paraaminosalisilat,fenulbutasol, diamos, ina, sidermitfenulbutasol, diamos, ina, sidermit

    +hemical materials+hemical materials

    "alnutrition ;D lac of maturation"alnutrition ;D lac of maturationfactorfactor