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CHAPTER I

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

1.2 Purpose and objectives

The intent and purpose of this case study tutorial report, namely:

1. As a tutorial group assignment report which is part of the KBK learning


system at the Faculty of Medicine in Muhammadiyah University Palembang.
2. Can resolve the case given in the scenario with the group discussion learning
analysis method.
3. The achievement of the objectives of the tutorial learning method.

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CHAPTER II

DISCUSSION

2.1 Tutorial Data

Tutor : dr. Indriyani , M.Biomed.

Moderator : Ahmad Rosihan

Desk secretary : Melenia Rhoma Dona YS

Board secretary : Dinda Arista

Time : Tuesday , September 24th 2019 ( 1st stage tutorial)

13.00 – 15.00 WIB

Thursday , September 26th 2019 (2nd stage tutorial)

13.00 – 15.00 WIB

2.2 Rules

1. Switch the phone off or in silent


2. Hold hand when asking question and arguments
3. Ask for permission in advance when going out of the room
4. Each tutor member is expected to wear marker

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)

2.5 Identification of Problem


1.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.

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%.

6.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.

2.6 Priority of problem


No.1. Because make other complication and disturb his daily activity.

2.7 Analysis of Problem


1. 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.
a. What is the meaning Mr.Sugiono came with a chief complain of languid
and frequent tiredness since 2 months ado and worsen on the current
weeks?
Answer:

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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)

b. How is the etiology of linguid and frequent tiredness?


Answer:
Lack of nutritional intake, because what is eaten is only rice and does not
eat vegetables, where the food which is contained contains little iron so
that the lack of blood which causes oxygen in the body's circulation
decreases and oxygen supply in the brain also decreases which causes mr.
Sugiono was languid, frequent tiredness and frequent headache.
(Fitriany,2018)

c. What is the relation of languid , frequent tiredness and frequent headche?


That is a condition in which the blood circulating in bloodstream is lower
than usual. The blood carry oxygen from lungs to other organs but in this
case organs might receive less oxygen.
Tiredness and languid happens because the body doesn’t have enough Hb,
less O2 reaches the tissues and muscles, deproving them of energy. In
addition, the heart has to work harder to move more oxygen-rich blood
around the body, whis can make tiredness and languid. When brain gets
less oxygen (hypoxia) than usual, we might experience headaches.
(Adamson, J.W.2015).

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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.

The physiology of blood:

Blood is an essential component in life, from primitive animals to human. In


physiological condisions, blood is always in the blood vessels so that it can
carry out its functions as :

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)

b. What is list of nutrions Mr.Sugiono should eat ?


Answer:
Nutrion for mr. Sugiono:
1.Animal-based iron sources
Chicken liver, beef, salmon, chicken.
2.Plant-based iron sources

Vegetables :Spinach,Potatoes.

(Supariasa, 2016).

c. What is the impact dislikes eating vegetable in general ?


Answer:
If intake of Vegetable is low, it can cause effect such as:

a. Increase blood cholesterol

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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.

b. Cause vision problem and decrease body immunity

In vegetables there is Vitamin A, vitamin A is important for growth,


visions and iincrease body immunity against infection.

c. Increase risk of constipation

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)

d. What is the clasification of anemia and explain?


Answer:
1. Morphological classification
Based on erythrocyte morphology on peripheral blood smear
examination or see erythrocyte index.

 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

e. What mechanisme of anemia ?


Answer:
Lack of nutrition food  iron reserve are decreasing  serum ferritin
decrease  iron supply can’t support eritropoiesis  transferrin
saturation decreases and serum iron decreased but TIBC increased  iron
which lead to erythroid bone marrow is not enough to cause decrease in
Hemoglobin  Iron Deficiency Anemia (Ozdemir, N.2015).

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.

a. What is the meaning of Mr.Sugiono didn’t have any history of worm


infestation ? A

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Answer:

The meaning is Eliminate defferential diagnosis. In this case not the


caused by worm infestation anemia.

b. What is the meaning of Mr.Sugiono didn’t go to malaria endemis area?

Answer:

Meaning is Mr.Sugiono didn’t suffer malaria to eliminate differencial


diagnosis of anemia hemolitik.

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.

d. What is the meaning of Mr.Sugiono didn’t getting blood tranfusion?


Answer:
The meaning is eliminate deffential diagnosis. In this case not caused by
thallasemia.

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:

Components In case Interpretation


Pale Vasoconstriction to peripheral
blood vessels
BP 90/60 Hypotention
Pulse 112x/minute Tachycardia
RR 20x/minute Normal (18-24x/minute)
Temp 36,8°C Normal (36,5 - 37,5°C)
Height 160 cm IMT = 17,57 (under weight)
Weight 45 kg
(Data Klinik Kemenkes, 2008)

b. How is the abnormal mechanism of physical examination?


Answer:
Underweight :

Insufficient intake of nutrition → High Intensity of activities →


Insufficient energy for body→ Body did lipolysis to fulfill the energy →
losing weight

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).

c. What is the interpretation of specific examination?

Answer:

Examination Interpretation
Head  Pale conjungtive Conjunctive anemis is indee
d one of the clinical signs of
anemia that is often encount
ered.(abnormal)

 No icteric sclera (Normal)

 Atropy papile The surface of the tongue be


comes slippery and shiny be
cause the tongue papilla
disappears

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(abnormal)

Neck  No lymph nodes e (Normal)


nlargement
 JVP (5-2) (Normal)

 Normal cor (Normal)


Thorax and pulmo
 Flat, supple, norm
al bowel sound, a
Abdomem nd no palpable (Normal)
hepar and lien

Extremites  Pale palmar pedis because peripheral tissues


and manus lack oxygen (abnormal)

 Koilonychia where nails turn brittle, verti


cal stripes and so concave th
at they look like spoons
(abnormal)

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(Kemenkes RI,2011)

d. How is the abnormal mechanism of specific examination?


Athropy papile
Lack of Fe intake → decreased Fe balance → impaired emoglobin
synthesis → globin biosynthesis inhibited by def via (HRI) → inhibition
of the main transcription factor for heme synthesis → decreased
hemoglobin concentration in blood → decreased blood transport
decreases → distribution oxygen to the disrupted tissue → papillary cell
injury → atrophy (Setiawan,A,Dkk.2014).

Pale Conjungtive, pale palmar pedis and manus


Increased Fe demand and less intake → decreased Fe reserves → if defici
ency contin-ues → empty Fe reserve → Fe supply for erythropoesis is dis
turbed → Hemoglobin level decreases → oxygen transport to tissue by
erythrosite decreases →oxygen is prioritized to vital organs → peripheral
vascular vasoconstruction → Pale conjungtive, palmar pedis and
manus (Setiawan,A,Dkk.2014).

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:

Laboratory Examination Normal Value


Hb: 8,1 g/dl Man:13-18 g/dl
(Anemia) Woman: 12-15 gr/dl
RBC: 3.800.000/mm3 Man:4.400.000-5.600.000/mm3
(Anemia) Woman:3.800.000-
5.000.000/mm3
Leukocyte: 8000/mm3 3.200-10.000/mm3
(normal)
ESR: 25 mm/hour Man: <15 mm/hour
(increased) Woman: <20 mm/hour
Diff Count: 0/1/20/58/20/1 0-2/0-6/0-12/36-73/15-45/0-10
(Neutrofil band increasing)
Ht: 26% Man: 40-50%
(decreased) Woman: 35-45%
Reticulocyte: 1% 0,5-2%
(normal)
(Kemenkes RI,2011)

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b.How is the abnormal mechanism of laboratory examination?

Answer:

Hb:

The need for Fe increases and the intake of Fe is less → Fe Reserves ↓ → if


the deficiency continues fare Fe reserves → The availability of Fe for
erythropoesis decreases erythropoesis is increasingly disrupted → Hb level
↓ (Sudoyo Aru W, 2009).

LED:

Inflamation → increased speed of RBC precipitating → increased LED

(Sudoyo Aru W, 2009)

Stem neutrophils are increased

Inflamation → neutrophils cells go to the inflammatory area → young


neutrophils are excreted in the inflamation area (stem neutrophils) → stem
neutrophils increase (Sudoyo Aru W, 2009)

RBC:
Intake of food (source Fe) is low → release inflammatory cytokines TNF-
alpha, IL-1 inhibiting erythropoiesis → number of erythrocytes formed
slightly (Sherwood, 2011).

6. 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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a.What is the interpretation of additional blood examination?

Answer:

Interpretation Normal range


MCV: 68 fl 80-94 fl
(Micrositer)
MCH: 21 pg 27-31%
(Hypochrome)
MCHC; 32 g/dl 30-35 gr/dl
(normal)
Fe serum: 12 ug/dl 60 – 150 µg/dL
(decreased)
Iron binding capacity: 540 ug/dl 300 – 360 µg/dL
(increased)
Serum feritin : 14 ug/dl 40 – 200 µg/dL
(decreased)
Blood smear: Hipocromic micrositer Normochrome normositer
(eliptical cell/ pencil cell)
(Kemenkes RI,2011)

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b. How is the abnormal mechanism of additional blood examination?

MCV

Iron deficiency anemia → plasma and fe increases → increase binding of iron


plasma hemoglobin (increase IBC) decrease hemoglobin → increases
hemoglobinis development of small RBC BC RBC (micrositer)

MCH

Iron deficiency anemia → decrease in serum iron → increase binding of iron


plasma hemoglobin (increase IBC) decrease hemoglobin → interfere with the
development of RBC hemoglobinization → pale RBC (hypochrome)
(Sudoyo Aru W, 2009).

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).

Decreased serum ferritin


The need for Fe is increased and Fe intake is slightly → Fe decreases in
plasma → the use of Fe (ferritin) reserves → The ferritin serum decreases.
(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%.

Additional blood examination : MCV 68 fl, MCH 21%, MCHC 31%, Fe


serum 12 ug, total iron binding capacity 550 ug/dl, feritinin serum 14 ug/dl.

Peripheral blood smear : anisocytosis, hypocrom micrositer, poikilocytsis

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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)

8. What is the additional examination in the case?


Answer:
- Protoporfirin red blood cells
Normally it is 20%, with iron deficiency anemia increasing to 200
- Transferring Saturation
Normal is 35 ± 15, the iron deficiency anemia increases to 40
(Lewis,2014)

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9. What is the working diagnosis in the case?
Answer:
Iron Deficiency Anemia

10. How is the therapy in the case?


Answer:
Pharmacology:
a) Oral iron: is the drug of first choice because it is effective, inexpensive, and
safe.
i. ferrous sulfate (ferrous sulfate), 3 x 200 mg dose.
ii. ferrous gluconate, ferrous fumarate, ferrous lactate, and ferrous
succinate
b) Parenteral iron: the more dangerous side effects, and are more expensive.
Mixture available: iron dextran complex, iron sorbitol, citric acid complex.
Can be administered intramuscularly or intravenously in slowly.
Requirement of iron (mg) = (15-Hb present) x BB x 3
Non-Pharmacology :
Causal therapy : depending on the cause
education: providing medical Consultations to Patients that anemia does not
recur
other treatment
i. Diet: should be given nutritious food with high protein primarily from
animal protein
ii. Vitamin C: Vitamin C is given 3 x 100 mg per day to increase of the
absorption of iron
iii. Blood transfusions: iron deficiency anemia rarely require blood
transfusions. An indication of blood transfusion on iron deficiency
anemia is the presence of heart desease anermic with the threat of

25
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)

11. What is the complication in the case?


Answer:
Complications of anemia, namely:
-infection and pneumonia
-complulsive urges to consume non food (pika)

-bleending

-Iron suplement overdosis

(kowalak,2017)

12. What is the prognosis in the case?


Answer:
Quo ad Vitam : Bonam
Quo ad Sanationam : Bonam
Quo ad Functionam : Bonam

13. What is the SKDU in the case?


Answer:
4A. Graduates of doctors are able to make clinical diagnoses and manage the
disease independently and thoroughly.

26
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.

2.9 Conceptual Framework

Low intake nutrition (meat and vegetarian)

Depletion of iron supply

Erythropoesis disturbed

Hemoglobin decreases

Iron deficiency anemia

languid, pale, koilonychia,frequent tiredness and


headache

27
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