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Rahma
h
Rahma
h
PATIENT IDENTITY
Name
: RTM
Age
: 4 years
Sex
: Male
MR
: 01.71.38.xx
Address
: Brojogaten, Yogyakarta
Ward
: Melati 4
CHIEF COMPLAINT
Pale and fever (referred from general hospital with 3rd day
of fever, anemia gravis)
Rahma
h
Rahma
h
4 days BA
Rahma
h
1 days BA
Rahma
h
Day of
Admission
Pale
Hematocrite 19,7%
MCV 57,4 fl
MCH 17,8 pg
MCHC 31,0
16,5
462
Family
PHYSICAL EXAMINATION
compos mentis
Vital Sign
HR : 108 x/minute
RR : 30 x/minute
T : 38oC
Rahma
h
Neck
: no palpable lymphnode, no
hyperemic pharyng, tonsil T1-T1
Thorax
Extremities
Head
Rahma
h
Rahma
h
NUTRITIONAL STATUS
Body weight
: 17 kg
W/U : 0 z 2
H//U : 0 z 2
H/W : 0 z 1
8/1/15
10.04
8/1/15
19.19
Erythrocyte
3,43
3,44
Hemoglobin
6,1
6,4
g/dL
11,5 - 16,5
Hematocrit
19,7
19,8
34 48
Leukocytes
6.900
9.200
/mm3
4.500 11.000
240.000
120.000
/mm3
150.000-450.000
Neutrophils
42
51
50-70
Lymphocytes
38
40,4
22-40
Monocytes
8,0
2-8
Eosinophils
0,5
2-4
Basophil
0,1
0-1
MCV
57,4
57,6
fL
80-99
MCH
17,8
18,6
pg
27-32
MCHC
31,0
32,3
g/dL
32-36
Platelet
Units
Normal Value
3,9-5,9
Rahma
h
Parameters
Fe
Iron saturation
TIBC
Feritin
8/1/15
Units
Normal
Value
32,0
mcg/dL
59-150
16
20-55
202
mcg/dL
228-428
884,67
ng/mL
68-434
Rahma
h
DATA LIST
Rahma
h
Pale
No organomegaly
RDW 28% (>14,5%), Menzter Index 16,5 (>13), RDW index 468 (>220)
ASSESSMENT
Rahma
h
Rahma
h
INTEGRATED PLANNING
No
1
Problem
Severe anemia cb iron
deficiency anemia
Patients Need
Establish the diagnosis
Plan
Monitoring vital signs
O2 NK 1 l/m
Elemental ferrous 4-6 mg/kgBW/day
Monitoring Hb level after 1 month
therapy
Monitoring sign of heart failure
Rahma
h
: no fever
O : Compos mentis
Pulse: 130 bpm, Temp : 37oC, RR 30 x/min, SpO2 99 %
O2 Nk 1 lpm
Neck : no palpable lymph node
Chest : symmetric, retraction (-)
Heart : S1 single, S2 split unconstant. Systolic
murmur.
Lungs : vesicular, wheezing -/-, ronchi-/ Abdomen : not distended, normal bowel sounds, no
liver and spleen enlargement
Extremity : Warm extremities, strong pulses, no edema,
CRT <2.
Assesment
Severe
P
Rahma
h
THANK YOU