PRELIMINARY
1.1. Background
Hematology and lymphatic blocks are the eighth block in the third semester of
the Curriculum Based on Medical Education Competency, Faculty of Medicine,
Palembang Muhammadiyah University. On this occasion a scenario case study B was
carried out Mr.Sugiono,a 35 years old scavenger brought to the internist polyclinic by
his family with a chief complain of languid and frequent tiredness since 2 months
ago and worsen on the current weeks.Mr.Sugiono also complains of frequent
headache. .Mr.Sugiono is only able to buy rice, with tempe adn tofu. Mr.Sugiono also
dislikes eating vegetables. Mr.Sugiono didn’t have any history of worm infestation,
went to malaria endemics area, and getting blood transfusion. Mr.Sugiono didn’t
have any other medical ilnesses.
Physical Examination :
General appearance : Looks pale, BP 90/60. Pulse : 112x/minute, RR : 20x/minute,
temp : 36,8 C, height : 160 cm, weight : 45 kg.
Specific examination :
Head : Pale conjungtive (+/+), Atrophy tongue papil (+), icteric sclera (-)
Neck :JVP (5-2) cm H20, Lymph nodes enlargement(-)
Thoraks : Normal cor and pulmo
Abdoment : Flat, supple, normal bowel sound,hepar and lien were not palpable.
Extremity: Pale palmar pedis and manus, koilonychia (+)
Laboratory Examination :
Blood test : Hb 8,1 g/dl, RBC 3,800.000/mm³, Leukocytes 8000/mm³, ESR 25
mm/hour, diff count 0/1/20/58/20/1 Ht 26 vol%, reticulocyte 1%
Additional blood examination:
MCV 68 fl, MCH 21 pg, MCHC 32 g/dl.
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Fe serum 12 ug/dl, iron binding capacity 540 ug/dl, serum feritin 14 ug/dl.
Blood smear: Hypochrom micrositer
The intent and purpose of this case study tutorial report, namely:
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CHAPTER II
DISCUSSION
2.2 Rules
2.3 Scenario
“Man In Pale”
Mr.Sugiono,a 35 years old scavenger brought to the internist polyclinic by his
family with a chief complain of languid and frequent tiredness since 2 months ago
and worsen on the current weeks.Mr.Sugiono also complains of frequent headache.
.Mr.Sugiono is only able to buy rice, with tempe adn tofu. Mr.Sugiono also dislikes
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eating vegetables. Mr.Sugiono didn’t have any history of worm infestation, went to
malaria endemics area, and getting blood transfusion. Mr.Sugiono didn’t have any
other medical ilnesses.
Physical Examination :
General appearance : Looks pale, BP 90/60. Pulse : 112x/minute, RR : 20x/minute,
temp : 36,8 C, height : 160 cm, weight : 45 kg.
Specific examination :
- Head : Pale conjungtive (+/+), Atrophy tongue papil (+), icteric sclera (-)
- Neck :JVP (5-2) cm H20, Lymph nodes enlargement(-)
- Thoraks : Normal cor and pulmo
- Abdoment : Flat, supple, normal bowel sound,hepar and lien were not
palpable.
- Extremity: Pale palmar pedis and manus, koilonychia (+)
Laboratory Examination :
Blood test : Hb 8,1 g/dl, RBC 3,800.000/mm³, Leukocytes 8000/mm³, ESR
25 mm/hour, diff count 0/1/20/58/20/1 Ht 26 vol%, reticulocyte 1%.
Additional blood examination:
MCV 68 fl, MCH 21 pg, MCHC 32 g/dl.
Fe serum 12 ug/dl, iron binding capacity 540 ug/dl, serum feritin 14 ug/dl.
Blood smear:
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2.4 Clarification of Term
1. Languid Having no energy (Dorland,2015)
2. Blood tranfusion Is the process of transferring blood products into
one’s circulation intavencusly (Dorland,2015)
3. Koilonychia Dystrophy of the fingernails with the nails becoming
thin and concave with the edge of the meningf
(Dorland,2015).
4. JVP The jugular venous pressure (JVP) is the indirectly
observed fressure over, the venous system via
visualization of the internal jugular vein
(Dorland,2015)
5. ESR An erythrocyte sedimentation (ESR) is a type of
blood test that measures how quickly erythrocytes
settle at the bottom of a test tube that contains a
blood sample (Dorland,2015)
2.Mr.Sugiono is only able to buy rice, with tempe adn tofu. Mr.Sugiono also dislikes
eating vegetables.
3.Mr.Sugiono didn’t have any history of worm infestation, went to malaria endemics
area, and getting blood transfusion. Mr.Sugiono didn’t have any other medical
ilnesses.
4.Physical Examination :
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General appearance : Looks pale, BP 90/60. Pulse : 112x/minute, RR : 20x/minute,
temp : 36,8 C, height : 160 cm, weight : 45 kg.
Specific examination :
- Head : Pale conjungtive (+/+), Atrophy tongue papil (+), icteric sclera (-)
- Neck :JVP (5-2) cm H20, Lymph nodes enlargement(-)
- Thoraks : Normal cor and pulmo
- Abdoment : Flat, supple, normal bowel sound,hepar and lien were not
palpable.
- Extremity: Pale palmar pedis and manus, koilonychia (+)
5.Laboratory Examination :
Blood test : Hb 8,1 g/dl, RBC 3,800.000/mm³, Leukocytes 8000/mm³, ESR 25
mm/hour, diff count 0/1/20/58/20/1 Ht 26 vol%, reticulocyte 1%.
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Languid, frequent tiredness and frequent headache are the clinical
manifestations of anemia and the conditions are progressive and a chronic
disease because mr. Sugiono already had the symptom since 2 months ago
and worsen on the current weeks (Fitriany,2018)
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d. How is the pathophysiology of languid and frequent tiredness and
frequent headche ?
Answer:
Inadequate iron intake causes the red blood cell-forming component
decreases resulting in the formation of erythrocytes is not optimal, which
causes decreased formation of hemoglobin. So the capacity of the blood to
carry oxygen to the brain reduced can make headache and low oxygen
supply to the extremitas can make tiredness and languid.
(Kowalak, 2017)
e. What are the posibble diseasse with languid and frequent tiredness,
frequent headche?
Answer:
1. Chronic fatigue syndrome
Chronic fatigue syndrome or myalgia encephalomyelitis is a condition
often easily tired and severe which lasts for at least 6 months. The cause of
this condition is unknown, but may include environmental or genetic
factors.
2. Glandular fever
Glandular fever is a viral infection that often causes symptoms of
fatigue, fever, sore throat and swollen glands. This disease often affects
teenagers and young adults.
3. Diabetes tipe 2
The body produces insulin but not enough. glucose is the fuel that will
be used as energy. in diabetes can not use glucose properly so that the
energy produced for activity is not enough and will make the body feels
fatique
4. Hypothyroidism
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The thyroid functions to control the body's metabolism to regulate the
speed of the body converting food into energy. if the thyroid does not
function properly it will cause metabolic disorders of the body and the
body will get tired faster.
(Ilmu penyakit Dalam Jilid II, 2014).
f. How the compensation of body when his condition languid and frequent
tiredness ?
Answer:
a) Pale: reduced blood volume, hemoglobin, vasoconstriction to
maximize the O2 supply to vital organs
b) Tachycardia and heart murmurs: Increased speed of blood flow reflect
the workload and cardiac output Increased to maximize the lack of
blood in the body
c) Dyspnea: compensation body to balance the lack of oxygen in the
lungs
(Pathophysiology Sylvia, 2006)
In severe anemia, Decreased blood viscosity this state Reduces the
resistance to blood flow in peripheral blood vessels so that the amount
of blood flowing through the tissue and then back to the heart far
exceeds normal consequently Increased cardiac output. In theory it
should be at the time of the body lack of blood will accelarate the rate
of heart to replace the lost blood in the body
(Guyton, 2017)
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g. What is physiology hematopoesis and physyology of blood?
Answer:
(Hoffbrand,2013)
Hemopoesis / Hematopoesis:
1. Yolk sac 0 - 3 months intrauterine
2. Liver and spleen 3-6 months intrauterine
3. Bone marrow 4 months - adult
Inside the bone marrow there are hemopoetic stem cells, one of the most
primitive is pluripotent stem cells.
a. Oxygen carrier
b. The body’s defense mechanism against infection
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c. Mechanism of hemostatis
(Bakta,2018).
2. Mr.Sugiono is only able to buy rice, with tempe adn tofu. Mr.Sugiono also
dislikes eating vegetables.
a. What of the meaning Mr.Sugiono is only able to buy rice with tempe and
tofu also dislikes eating vegetable?
Answer:
The meaning is Mr. Sugiono is malnutrition. Vegetable rich sourch of the
iron and vitamin C. without enough iron, the body will make fewer RBCs
or will produce smaller RBCs than normal. Without enough Vitamin C,
the iron can not be optimally absorbed or utilized by the body.
(Adamson, J.W.2015)
Vegetables :Spinach,Potatoes.
(Supariasa, 2016).
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Vegetables are rich of fiber, if we eat little amount of fiber it can cause
excess cholesterol in our body. Fiber can prevent or decrease fat
absorption in our body so it can help decreasing blood cholesterol.
Lack of fiber can cause our feces to hardened so it make our body
require a bbigger contraction of muscle which can lead to constipation
( Ruwaidah, 2007)
Microcytic hypochromic anemia (MCV <80 fl; MCH <27 -34 pg)
- Iron deficiency anemia
- Thalassemia
- Anemia due to chronic disease
- Sideroblastic anemia
Normochrom micnormositer anemia (MCV 80-95 fl; MCH 27-34
pg)
- Post-bleeding acute anemia
- Aplastic anemia / hypoplastic
- Hemolytic anemia
- Mieloplastic anemia
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Macrositer anemia (MCV> 95 fl)
- Megaloblastic
a. Folate deficiency anemia
b. Vit B12 deficiency anemia
- Non megaloblastic
a. Hypothyroidism anemia
b. Anemia in myelodysplastic syndrome
( Lewis,2014 )
2. Based on degree
- Very low Hb: 10 g/dl
- Light Hb: 8 g/dl – 9,9 g/dl
- Moderate Hb: 6 g/dl -7,9 g/dl
- Heavy Hb: <6 g/dl
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Answer:
Answer:
c. What is the meaning of Mr.Sugiono didn’t have any other medical ilness?
Answer:
The meaning is eliminate deffential diagnosis. In this case not caused by
chronic disease such as chronic ren failure, acute leukemia and chronic
hepar disease.
4. Physical Examination :
General appearance : Looks pale, BP 90/60. Pulse : 112x/minute, RR :
20x/minute, temp : 36,8 C, height : 160 cm, weight : 45 kg.
Specific examination :
- Head : Pale conjungtive (+/+), Atrophy tongue papil (+), icteric sclera (-)
- Neck :JVP (5-2) cm H20, Lymph nodes enlargement(-)
- Thoraks : Normal cor and pulmo
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- Abdoment : Flat, supple, normal bowel sound,hepar and lien were not
palpable.
- Extremity: Pale palmar pedis and manus, koilonychia (+)
a. What is the interpretation of physical examination?
Answer:
Tachycardia :
Risk factors no Fe intake decreased Fe reserves Continued use of
Fe Decreased Fe supply for erythropoesis Continuous Fe use
Empty Fe reserves Erythropoesis in the bone marrow is disrupted
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Heme formation and decreased globin Decreased hemoglobin
synthesis Ability to oxygen binding decreases oxygen focus to vital
organs decreases vasoconstriction Tachycardia.
Hypotension
When the body is deficient supply of oxygen (hypoxia) then will dilate
peripheral blood vessels thereby increasing the amount of blood
returning to heart and cardiac output can be Increased 3-4 times than
normal. But if people are Anemic physical activity then the heart is
Unable to replace or balancing the supply shortage of blood in the body
so that if left unchecked can causing serious tissue hypoxia, acute heart
failure and circulatory collapse (Shock) (Guyton, 2017).
Answer:
Examination Interpretation
Head Pale conjungtive Conjunctive anemis is indee
d one of the clinical signs of
anemia that is often encount
ered.(abnormal)
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(abnormal)
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(Kemenkes RI,2011)
Koilonychia
Koilonychia is known as one of the clinical manifestations of iron deficie
ncy anemia. in addition to the presence of koilonika iron deficiency found
in protein deficiency, hemochromatic, plumer vinson syndrome, scleroder
ma and can also be associated with trauma both physical and chemical tra
uma (Setiawan,A,Dkk.2014).
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5. Laboratory Examination :
Blood test : Hb 8,1 g/dl, RBC 3,800.000/mm³, Leukocytes 8000/mm³,
ESR 25 mm/hour, diff count 0/1/20/58/20/1 Ht 26 vol%, reticulocyte
1%.
a.What is the interpretation of laboratory examination?
Answer:
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b.How is the abnormal mechanism of laboratory examination?
Answer:
Hb:
LED:
RBC:
Intake of food (source Fe) is low → release inflammatory cytokines TNF-
alpha, IL-1 inhibiting erythropoiesis → number of erythrocytes formed
slightly (Sherwood, 2011).
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a.What is the interpretation of additional blood examination?
Answer:
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b. How is the abnormal mechanism of additional blood examination?
MCV
MCH
Decreased serum Fe
The need for Fe increases and the intake of Fe is small → Fe Reserves ↓ →if
the deficiency continues → Empty Fe Reserves Fe ,Fe supply for erythropo is
reduced→ eritropoesis is increasingly disrupted → Hb levels ↓ →formed
erythrocytes that are micrositer (Sudoyo Aru W, 2009).
IBC increases
Fe demand increases and iron intake is slightly →Fe decreases in plasma →
the use of Fe (ferritin) reserves → ferritin decreases → Fe decreases in serum
→ apotransferin binding capacity to iron increases → IBC increases
(Sudoyo Aru W, 2009).
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5. How to diagnosis?
Answer:
a. History
Chief complain of languid and frequent tiredness since 2 month ago and
headache,didn’t have any history of worm infestation, went to malaria
endemics area, and getting blood transfusion. didn’t have any other medical
illnesses ,able to buy rice, with tempe and tofu. dislikes eating vegetables.
b. Physical examination
General Appearance: look pale, BP 90/60 mmHg, Pulse 112x/m, RR 20x/m,
temp 36,8 C, BH 160cm, BW 45kg
c. Specific Examination:
Head : Pale Conjungtive (+/+), Atrophy tongue papil (+), Icteric Sclera (-)
Neck : JVP (5-2) cm H2O, Lymph nodes enlargement (-)
Thoraks : Normal Cor and Pulmo
Abdomen : Flat, Supple, normal bowel sound, hepar and lien were not
palpable
d. Laboratory examination
Blood Chemistry : Hb 8,1 g/dl, RBC 3.800.000/mm3, leukocyte 8000/mm3,
ESR 25 mm/hour, Diff Count 0/1/20/58/20/1 Ht 26Vol%, reticulocyte 1%.
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7. What is the differential diagnosis in the case?
Answer:
Iron Deficiency Anemia due to Sideroblastic
Anemia chronic disease Anemia
Degrees of light until heavy light light until heavy
anemia
MCV Decrease Decrease/normal Decrease/normal
MCH Decrease Decrease/normal Decrease/normal
Iron Serum Decrease < 30 Decrease <50 Normal/increase
TIBC Increase >360 Decrease <300 Normal/ Decrease
Saturasi Decrease < 15% Decrease / normal Increase >20%
Transferin 10-20%
Fe Bone Negative Positive Positive with the
Marrow sideroblast ring
Protoporfirin Increase Increase Normal
eritrosit
Ferittin Decrease < Normal 20-200µg/l Increase >50µg/l
serum 20µg/l
Elektroforesis Normal normal Normal
HB
(Adamson, J.W.2015)
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9. What is the working diagnosis in the case?
Answer:
Iron Deficiency Anemia
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heart failure, the which is very symptomatic anemia, and Patients
require a rapid improvement in hemoglobin levels. Given blood type
is PRC (packed red cells) to reduce the danger of overload, as
premedication may Consider granting intravenous furosemide
(Bakta, 2018)
-bleending
(kowalak,2017)
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14. NNI
Answer:
ام ِه َ سان إِلَى
ِ َطع ِ فَ إليَ إنظ ِر إ
َ اْل إن
Then the man should pay attention by putting his wits (on the food) how the
food was created and arranged for him ( Abasa: 24).
2.8 Conclusion
Mr.Sugiono, 35 years old complained languid, frequent tiredness and
headache et causa iron deficiency anemia caused by low intake nutrition.
Erythropoesis disturbed
Hemoglobin decreases
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REFERENCES
Fitriany.2018. Anemia Defisiensi Besi : Jurnal Averrous Vol.4 No.2 (hlm. 123-
129).Aceh: 1 SMF Ilmu Kesehatan Anak, Fakultas Kedokteran, Universitas
Malikussaleh, Aceh, Indonesia.
Ruwaidah, Amin. 2016. Penyakit Akibat Lalai Mengkonsumsi Buah dan Sayur serta
Solusi Penyembuhannya.
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Sherwood, L. 2012. Fisiologi manusia dari sel ke sistem. Jakarta: EGC.
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