Incase 080115 Rara

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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