INTERESTING CASE

Thursday, January 8th, 2015

Hendra, Mutia, Frida, Sari, Melia, Kaka, Umi, Rahmah,

Gina, Danar

INTERESTING POINT

Iron deficiency anemia with unclear risk factors

Rahma
h

Rahma
h

PATIENT IDENTITY

Name

: RTM

Age

: 4 years

Sex

: Male

MR

: 01.71.38.xx

Address

: Brojogaten, Yogyakarta

Ward

: Melati 4

CHIEF COMPLAINT

Pale and fever (referred from general hospital with 3rd day
of fever, anemia gravis)

Rahma
h

Rahma
h
4 days BA

Patient got sudden high fever (39,5oC) given

paracetamol resolved

No vomitus, no cough, no coryza, no complaint when

defecation/miction.

Rahma
h
1 days BA

Parents realized the patient was pale

Rahma
h
Day of
Admission

Pale

No fever, no vomitus, no cough

Brought to emergency room

Leucocyte

6.900 /l Erythrocyte 3.430.000

Hemoglobin 6,1 g/dL

Hematocrite 19,7%

MCV 57,4 fl

MCH 17,8 pg

MCHC 31,0

g/dL Platelete count 240.000 /L

RDW 28 % Index menzer

RDW index

16,5

462

Referred to Sardjito hospital atas permintaan orang tua

 Family

history : mother was diagnosed anemia

since 6 months ago, got red blood transfusion 2x,
was told kurang asupan. Hemoglobin level was
6 g/dl no futher investigation

PHYSICAL EXAMINATION

General appearances : look pale, dyspneu

compos mentis

Vital Sign

HR : 108 x/minute

RR : 30 x/minute

T : 38oC

SpO2 : 99% (O2 NK 1 l/m)

Rahma
h

 Neck

: no palpable lymphnode, no
hyperemic pharyng, tonsil T1-T1

Thorax

: symmetric, no retraction, no left

movement
Lung : vesicular normal on both lungs,
ronchi (-), wheezing(-)
Heart : single S1, S2 split unconstantly,
systolic murmur Abdomen : no
abdominal distension, normal peristaltic
sound, no shifting dullness, no liver and
spleen enlargement

Extremities

: warm extremities, strong

pulse, CRT <2 seconds, pale (+)

Head

: anemic conjunctiva (+)

Rahma
h

Rahma
h

NUTRITIONAL STATUS

Body weight

: 17 kg

Body height : 105 cm

W/U : 0 z 2
H//U : 0 z 2
H/W : 0 z 1

Good nutritional status

ROUTINE BLOOD EXAMINATION

Parameters

8/1/15
10.04

8/1/15
19.19

Erythrocyte

3,43

3,44

Hemoglobin

6,1

6,4

g/dL

11,5 - 16,5

Hematocrit

19,7

19,8

34 48

Leukocytes

6.900

9.200

/mm3

4.500 11.000

240.000

120.000

/mm3

150.000-450.000

Neutrophils

42

51

50-70

Lymphocytes

38

40,4

22-40

Monocytes

8,0

2-8

Eosinophils

0,5

2-4

Basophil

0,1

0-1

MCV

57,4

57,6

fL

80-99

MCH

17,8

18,6

pg

27-32

MCHC

31,0

32,3

g/dL

32-36

Platelet

Units

Normal Value
3,9-5,9

Rahma
h

Parameters
Fe
Iron saturation
TIBC
Feritin

8/1/15

Units

Normal
Value

32,0

mcg/dL

59-150

16

20-55

202

mcg/dL

228-428

884,67

ng/mL

68-434

Rahma
h

Blood smear : anisositosis,

polychromation, target cell, tear
drop cell

DATA LIST

Rahma
h

Male, 4 yo, Yogya

Pale

No organomegaly

Systolic murmur (anorganic)

Hb 6,4 MCV 57,6 MCH 18,6 MCHC 32,3

RDW 28% (>14,5%), Menzter Index 16,5 (>13), RDW index 468 (>220)

Blood smear : anisositosis, polychromation, target cell, tear drop cell

Severe anemia cb iron deficiency anemia

ASSESSMENT

Severe anemia cb iron deficiency anemia

Rahma
h

Rahma
h

INTEGRATED PLANNING
No
1

Problem
Severe anemia cb iron
deficiency anemia

Patients Need
Establish the diagnosis

Plan
Monitoring vital signs
O2 NK 1 l/m
Elemental ferrous 4-6 mg/kgBW/day
Monitoring Hb level after 1 month
therapy
Monitoring sign of heart failure

CONDITION THIS MORNING

S

Rahma
h

: no fever
O : Compos mentis
Pulse: 130 bpm, Temp : 37oC, RR 30 x/min, SpO2 99 %
O2 Nk 1 lpm
Neck : no palpable lymph node
Chest : symmetric, retraction (-)
Heart : S1 single, S2 split unconstant. Systolic
murmur.
Lungs : vesicular, wheezing -/-, ronchi-/ Abdomen : not distended, normal bowel sounds, no
liver and spleen enlargement
Extremity : Warm extremities, strong pulses, no edema,
CRT <2.

 Assesment
Severe
P

anemia cb iron deficiency anemia

: continue the previous plan

Rahma
h

THANK YOU