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Case ReportIron Deficiency Anemia

Presented byAji Witama, S.ked

Supervisordr. Sumardi Fransiskus, M.biomed, Sp.A

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Patient IdentityName : An. OSex : GirlAge : 2 year 9 monthReligion : KatolicAddress : Jln. Padang Pasir RT

020/004 Kec.Singkawang SelatanDate of birth : 09 April 2012Date of hospitalization : 12

January 2015

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AnamnesisMain Complaint

Pale and weak since 2 months before hospitalization

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Anamnesis

Meaningful findingHistory of the present ill

◦Looked pale since 2 months before hospitalization

◦Pale was not associated or induced by fever

◦Pasient didn’t complain about bruised, epistaxis, gums bleeding or joint swelling.

◦Defecation and urinate pattern was the same as usual

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Anamnesis

History of the past illSince the first year of life, she often

had fever and coughEasily got weak, pale, and tiredNever had history of the skin turning

blue during cryingHistory of the family illThere’s no history of haematology

disorder such as thallasemia or leukemia in her family

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Anamnesis

History of mother’s pregnancyNever consumed

“jamu” or other drugs without doctor prescription

Never had fever or fluor albus

ANC 4 times at primary health service

History of laborAterm,

spontaneous, at Abdul Aziz hospital, crying immediately.

Birth weight 2500 grams, birth length 48,5 cm, clear amniotic fluid

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Anamnesis

Feeding historyThe patient consumes formula

milk from birth until now and tends to drink it much more than the other meals, such as porridge.

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Anamnesa

History of immunizationComplete basic immunization

History of growth and developmentDifficult to gain weight since 1 year

oldPatient has been able to walk, to

scratch with pencil, to speak 2 comprehensible words, to put the toys, and to play with ball.

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Genogram

: Patient

67 yr 68 yr52 yr62 yr

30 yr 28 yr 25 yr 22 yr 32 yr 28 yr 27 yr

2 yr

24 yr

1 yr

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Physical Examination

Vital SignBP : 80/60 mmHgRR : 122 x/menitHR : 42 x/menitT : 36,7o C

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AntropometriHeight : 82

cmWeight : 9 kg

W/A : underweightH/A : normalW/H : wasted

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Physical Examination

List of Problem• Skin : Pallor (+)• Eyes : conjunctival pallor (+)• Extremity : weak pulsation of

peripheral artery and palmar pallor (+)

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Laboratorium Finding

Parameter Standard 12/01/15 14/01/15

WBC

RBC

HGB

MCV

MCH

MCHC

RDW

HCT

PLT

LED

3.6-11.0 gr/l

4.20-6.20 x 106/l

11.7-17.3 g/dl

80-100 fl

26-34 pg

31-35,5 g/dl

10,5-14,5 fl

38.0-54-0 %

150-440 x 103/l

0-20 mm/hour

8,2 x 103 gr/l

2,29 x 106/l

5,7 g/dl

65,8 fl

25,0 pg

35,1 g/dl

10,9 fl

15,1 %

405 x 103/l

2 mm/hour

10,2 x 103 gr/l

3,94 x 106/l

10,3 g/dl

73,4 fl

26,2 pg

35,7 g/dl

25,8 fl

28,9 %

356 x 103/l

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DiagnosisSuspect iron deficiency anemia

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TreatmentIVFD Asering 15 dpm (macro)Ceftriaxone iv 2x300 mgRanitidin iv 2x10 mgDexametason iv 0,9 mg (protransfusion)Furosemid iv 10 mg (posttransfusion)Novaldo iv 100mg (prn >38,50 C)Paracetamol syr 4xcth IMultivitamin syr 1xcth IFolat acid 1x1 tabPirantel Pamoat p.o 1x 100mgTransfusion PRC 200cc (2x)

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Prognosis

Quo ad Vitam : Ad Bonam

Quo ad Functionam : Ad Bonam

Quo ad Sanactionam : Ad Bonam

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CASE ANALYSIS

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Anamnesis

TheoryLong term pale

without bleeding manifestation

Easily tired and weak

Milkaholics

PatientLooked pale and

weak since 2 months ago

Epistaxis (-), gums bleeding (-)

She was easily tired during activity

She likes to drink formula milk more than the other meals

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Physical Examination

Patient• Skin : pallor (+)• Eye : pallor

conjungtival (+)• Extrimity : weak

pulsation of peripheral artery and palmar pallor (+)

• Organomegaly (-)• W/H : wasted

TheoryIrritable and anorexiaPale (found in level of

Hb <7 g/dL)Without organomegalyKoilonychia, glositis,

stomatitis angularis, tachicardia, heart failure

Disturbance of growth and development

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Laboratory Finding

Patient

Lower level of

◦ RBC

◦ HGB

◦ MCV

◦ MCH

TheoryComplete blood

count shows micrositer hipochromic anemia with lower level of MCV and MCH index, increased of RDW, decreased RBC count, WBC can be normal, and increased or normal platelet count.

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Laboratory Finding

PatientMetzner index in

this patient is 28,3 with RDW index 308,4

TheoryIron deficiency

anemia can be suspected in patient with metzner index >13 and RDW index > 220

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Diagnosis

PatientAnamnesis

Anemia without bleeding manifestation (+)

Physical ExaminationThere’s no organomegali

Laboratory FindingLower level of : RBC, HGB, MCV, MCH

TheoryLow level of Hb for

appropriate ageMCH 31% (N: 32-

35%)Level of Fe serum

<50 μg/dL (N: 80-180 μg/dL)

Trasferrin saturation <15% (N: 20-50%)

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Diagnosis

PatientAnamnesis

Anemia without bleeding manifestation (+)

Physical ExaminationThere’s no organomegali

Laboratory FindingLower level of : RBC, HGB, MCV, MCH

TheoryIn minimal facility

place: Anemia without

bleeding Without organomegali Peripheral smear:

microcytic, hypochromic red blood cells

Respond to iron trial therapy

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TreatmentPatient IVFD Asering 15 dpm

(macro) Ceftriaxone iv 2x300 mg Ranitidin iv 2x10 mg Dexametason iv 0,9 mg Furosemid iv 10 mg

(posttransfusi) Novaldo iv 100mg (prn

>38,50 C) Paracetamol syr 4xcth I Multivitamin syr 1xcth I Folat acid 1x1 tab Pyrantel Pamoat p.o 1x

100mg Transfusion PRC 200cc (2x)

Theory Iron products

parenteral or peroral Antibiotic to avoid

secondary infection Symptomatic Erythropoiesis Pyrantel Pamot

empyric therapy Transfusion to

maintain tissue perfusion

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Prognosis

PatientQuo ad vitam

Ad BonamQuo ad

Functionam Ad Bonam

Quo ad Sanactionam Ad Bonam

TheoryGenerally,

patients with iron deficiency anemia that is only caused by iron deficiency have a good prognosis when treated with sufficient intake of iron

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