aiha case dr irwin
TRANSCRIPT
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Autoimmune Hemolytic Anemia
Case Report
dr. Irwin, Sp. PD
Mimi Suhaini bt Sudin
030.08.309
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ANAMNESE
ANAMNESE AND AUTO ANAMNESE ON
15th OCTOBER 2012 AT 8 am
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IDENTITY
Name Mrs T
Age 37 years old
Sex Female
Address Cemara
Occupation Housewife
Religion Islam
Marital status MarriedDate of admission 14rd October 2012
Taken from Rengasdengklok Dormitory
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PICTURE OF PATIENT
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ANAMNESE
Abdominal discomfort atupper left quadrant sincea weeks ago
MAINCOMPLAINT
Malaise, shortness of
breath, headache, paleskin colourADDITIONAL
COMPLAINT
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History of present illnessMrs T came to Emergency Room of RSUD Karawang because
of abdominal discomfort at the upper left quadrant since aweeks ago before admitted .She said that a mass grows at the
upper left quadrant of her abdomen and it is starting to grow
smaller in size and becomes bigger as times goes by since a
year ago. She has had a pale looks, fatigue, weakness, and
shortness of breath with exertion during the past 4-5 days. On
admission, the patient denied fever, chest pain, nausea and
vomiting .She has headache, sweating and palpitation
intermittently. She complains that her weight has lost since a
year ago and she lost her appetite since sick. She denied thather urine colours looks like tea. She admits that her
menstruation period doesnt last long with duration 2 days and
only little in quantity. She denied that she has gone to any
countryside.
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History of past illness
Same symptom
(-)
Hypertension
(-)
Diabetes
(-)
Food and DrugAllergy
(-)
Heart Disease
(-)
Liver Disease
(-)
Malignancy
(-)
Asthma
(-)
Kidney disease
(-)
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Family history
Same symptom
(-)
Hypertension
(-)
Diabetes
(-)
Asthma
(-)
Heart Disease
(-)
Liver Disease
(-)
Malignancy
(-)
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History of treatment
She never been admitted to any hospital before
She eats bodrex when ever feels headache
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PERSONAL AND SOCIETY HISTORY
Herbal medicine (+)
Blood transfusion (-)
Alcohol (-)Vaccination
(-)
smoking(-)
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Physical Examination
General Condition
Appearance : moderately ill
Consciousness : compos mentis
Nutritional status : 157cm , 52kg
21.09 kg/cm2(NORMAL)
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VITAL SIGN
Blood pressure
120/80
Heart rate
80x/m
Temperature
36.5 C
Respiration rate
20 x / m
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PHYSICAL EXAMINATION
Normocephaly, black-haired and evenly distributedHead Anemic conjuctiva +/+, Icteric sclera -/-
Direct and indirect light reflexes +/+Eyes
Normotia, ear secretion -/-, hyperemic -/-, tragus pain -/- Auricula pain -/-, intact tympani membrane +/+Ears
Nose
Mouth
Neck
Septum deviation -, hyperemic concha -/-, nasal
discharge -/-, nostril breathing -
Red lip +, dry -, oral hygiene +, pharyngeal arc
symetrical, tonsil T1-T1 in normal measure
Unpalpable lymph node and thyroid, JVP: 5+2 cmH2O
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ThoraxINSPECTION
Ictus cordis is invisible
PALPATION
Ictus cordis is palpable at 5th ICS LMCS
PERCUTION
Right heart border: ICS III-V LSD
Left heart border: ICS V 1cm medial LMCS
Upper heart border: ICS III LPSS
AUSCULTATION
Regular I - II absence of murmurs and gallop inhearts sound
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Thorax
INSPECTION
Symmetrical in shape
PALPATION Equal vocal resonance
PERCUTION
Sonor in both lungs
AUSCULTATION
Vesicular breathing sound in both lung, ronchi -/- ,wheezing -/-
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Abdominal ExaminationINSPECTION
Brown skin, flat abdomen, icteric(-), caput medusa
PALPATION
Pain at epigastrium (+)
Hepatomegaly (-)
Splenomegaly (+), schuffner 5
PERCUTION
No pain present on abdominal percussion
Dullness (+) at upper left quadrant , shifting dullness (-)
AUSCULTATION
Bowel sound(+), arterial bruit (-), venous hum (-)
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Extremities Examination
WARM
ACRALS
+ +
+ +OEDEM
- -
- -
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Laboratory Examination (OCTOBER 14th 2012)
Haematological
Parameter
Result Normal Value
Haemoglobin 5,9 gr/dl 12 17 gr%
Leukocyte 10000/mm3
5 000
10 000/LTrombocyte 283 000 150 000 450 000
Haematocryte 20 % 37 43 %
Blood glucose level 102 mg/dl 80 140 mg/dl
Ureum 40 mg/dl 10 45 mg/dl
Creatinine 0,61 mg/dl 0,4 1,5 mg/dl
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Laboratory Examination (OCTOBER 14th 2012)
Haematological
parameter
Result Normal value
Basophils 0 (0 1) %Eosinophils 0 (1 - 3) %
Rod Neutrophils 0 (2 - 6) %
Segmen Neutrophils 77 (40 - 70) %Lymphocytes 19 (20 - 40) %
Monocytes 4 (2 - 8)%
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Laboratory Examination (OCTOBER 15th 2012)
Haematological
Parameter
Result Normal Value
Total Bilirubin 1,12 mg/dl
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The peripheral blood film (OCTOBER 15th 2012)
Based on the peripheral blood film, the picture of
the blood are:
erythrocyte : anisopoichilocytosispolychrome,basophilic stippling (+) , cabot ring (+)
Leukocyte : there is no abnormal morfology
Trombocyte : there is no abnormal morfology
Effect : microcytic anemia
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The comb test (OCTOBER 15th 2012)
The comb test is done and the
result is positive
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- Abdominal discomfort
at upper left quadrant
- A mass becomes bigger
in size since a year ago
-Pale looks,
fatigue,weakness,
shortness of breath
-Fever (-)
-chest pain(-)
-nausea(-)
-Vomitting (-)-Headache,sweating
,palpitation intermittenly
-Loss weight
-Urin colour like tea(-)
- CA +/+
-Pain at epigastrium
-Splenomegaly
(+),schuffner 5
--dullness (+) at theupper left quadrant
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-Hb : 5,9 %
-Ht : 20%
-Segmen neutrophil : 77
-Lymphocytes :19
-Total bilirubin : 1,12 mg/dl
-Indirect bilirubin: 0,82mg/dl
-Peripheral blood : microlytic
anemi
- comb test : positive
ResumeHistory taking Physical
examinationLaboratory
findings
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DIFFERENTIAL DIAGNOSIS
Iron deficiency anemia
Autoimmune hemolytic anemia
Lien tumor Malaria
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WORKING DIAGNOSIS
AIHA ( Autoimmune hemolytic anemia)
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Suggested Examination
Iron serum
TIBC
USG abdomen
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THERAPY
PHARMACOLOGY
- IVFD aminofluid Asering 1:1
- Prednisolon 1mg/kg/day- Sangobion 1x1
NON
PHARMACOLOGY
- PRC transfusion 3kolf
-Suggested to
splenectomy
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PROGNOSIS
AD VITAM
Ad bonam
ADFUNCTIONAM
Dubia Adbonam
ADSANATIONAM
Dubia adbonam
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