INTERESTING CASE Monday, December 1st, 2014
INTERESTING CASEThursday, January 8th, 2015Hendra, Mutia, Frida,
Sari, Melia, Kaka, Umi, Rahmah, Gina, DanarINTERESTING POINTIron
deficiency anemia with unclear risk factorsRahmahPATIENT
IDENTITYName: RTMAge: 4 yearsSex: MaleMR: 01.71.38.xxAddress:
Brojogaten, YogyakartaWard: Melati 4RahmahCHIEF COMPLAINTPale and
fever (referred from general hospital with 3rd day of fever, anemia
gravis)RahmahPatient got sudden high fever (39,5oC) given
paracetamol resolvedNo vomitus, no cough, no coryza, no complaint
when defecation/miction.4 days BARahmahParents realized the patient
was pale1 days BARahmahPale No fever, no vomitus, no coughBrought
to emergency room Leucocyte6.900 /lErythrocyte3.430.000Hemoglobin
6,1 g/dLHematocrite 19,7%MCV 57,4 fl MCH 17,8 pgMCHC
31,0g/dLPlatelete count 240.000 /LRDW 28 %Index menzer 16,5RDW
index 462Referred to Sardjito hospital atas permintaan orang
tua
Day of AdmissionRahmahFamily 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
investigationPHYSICAL EXAMINATIONGeneral appearances : look pale,
dyspneucompos mentisVital SignHR : 108 x/minuteRR : 30 x/minuteT :
38oCSpO2 : 99% (O2 NK 1 l/m)
Rahmah
Neck : no palpable lymphnode, no hyperemic pharyng, tonsil
T1-T1Thorax : symmetric, no retraction, no left movementLung :
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 enlargementExtremities : warm
extremities, strong pulse, CRT 14,5%), Menzter Index 16,5 (>13),
RDW index 468 (>220)Blood smear : anisositosis, polychromation,
target cell, tear drop cellSevere anemia cb iron deficiency
anemiaRahmahASSESSMENTSevere anemia cb iron deficiency
anemiaRahmahINTEGRATED PLANNINGNoProblem Patients NeedPlan1Severe
anemia cb iron deficiency anemiaEstablish the diagnosis
Monitoring vital signsO2 NK 1 l/mElemental ferrous 4-6
mg/kgBW/dayMonitoring Hb level after 1 month therapyMonitoring sign
of heart failure RahmahCONDITION THIS MORNINGS : no feverO : Compos
mentisPulse: 130 bpm, Temp : 37oC, RR 30 x/min, SpO2 99 % O2 Nk 1
lpm Neck : no palpable lymph nodeChest : symmetric, retraction
(-)Heart : S1 single, S2 split unconstant. Systolic murmur.Lungs :
vesicular, wheezing -/-, ronchi-/-Abdomen : not distended, normal
bowel sounds, no liver and spleen enlargementExtremity : Warm
extremities, strong pulses, no edema, CRT
