CASE STUDY ANEMIA

1. April was a 45-year-old. She reported feeling nauseous and tired and, curiously, she
thought her skin had taken on a yellow colour. When pressed for further symptoms she
admitted to shortness of breath on exercise and possibly weight loss but denied
abdominal pain, dysphagia, rectal bleeding, change in bowel habit or change in colour of
stool or urine.

April thought her symptoms may have first appeared around six months previously but
had become progressively more intrusive since then. Although April 's sclera looked clear
her skin did appear to have a yellow tinge to it. She was not tachypnoeic at rest but was
tachycardic, with a regular pulse of 108 beats per minute. Her chest was clear, heart
sounds were normal and there was no calf swelling or tenderness. Abdominal
examination revealed no tenderness, masses or organomegaly.

Her blood tests showed a severe macrocytic anaemia with a haemoglobin of 5.2 g/dL and
a mean cell volume (MCV) of 112 fL. Her white cell count was 4.000/L, although
platelets were on the low side at 131.000/L. Erythrocyte Sedimentation Rate of 30 mm.
There was absence of a significant reticulocytosis. Her bilirubin indirect level was
elevated to 5,9 mg/dL with other Liver Function Tests normal. Thyroid Function Tests
and fasting glucose levels were normal.

What else laboratory test should you suggest to make diagnosis?

a. Hb electrophoresis
b. Peripheral blood smear
c. Folic acid and B12 level
d. Total Iron Binding Capacity
e. Occult blood test and Coombs test

What is possible diagnosis for this patient?

a. Blood loss
b. Hemolytic anemia
c. Fe defficiency anemia
d. Myelodysplastic syndrome
e. Megaloblastic anemia

2. A 23-year-old woman was referred to our institution for evaluation of anemia. She was
known to have multiple comorbidities and had a baseline hemoglobin concentration of
approximately 10.5 g/dL. About 6 months before her referral, the patient began having
recurrent episodes of severe anemia, with hemoglobin values as low as 3.5 g/dL. She had
become transfusion-dependent and had received about 30 units of packed red blood cells
(RBCs) in the preceding 3 months. The patient denied any history of easy bruisability,
menorrhagia, or overt evidence of bleeding from any site. Additionally, she denied any
change in the appearance or color of her urine and had no history of jaundice. There was
no family history of anemia or any other hematologic disorder.

At presentation, the patient's vital signs were normal. Physical examination was
unremarkable except for mild generalized pallor. A complete blood count on the day of
admission revealed the following (reference ranges shown parenthetically): hemoglobin,
4.9 g/dL (12.0-15.5 g/dL); mean corpuscular volume (MCV) 94.4 fL (81.6-98.3 fL);
hematocrit 13.4% (34.9%-44.5%); leukocyte count 6.0 103/L (3.5-10.5 103/L); and
platelet count 203 103/L (150-450 103/L).

Which one of the following is the least likely in the differential diagnosis of this
patient's anemia?

f. Blood loss
g. Hemolysis
h. Fe defficiency
i. Myelodysplastic syndrome
j. Acquired pure red cell aplasia

Which one of the following would be the next best test to narrow the list of differential
diagnoses?

a. Erythropoietin
b. Reticulocyte count
c. Peripheral blood smear
d. Serum iron and ferritin
e. Bone marrow aspiration

If this patient had a reticulocytosis of 13.3% (0.60%-1.83%), with an absolute

reticulocyte count of 238.8 103/L (29.5-87.3 103/L), which one of the following
series of tests would be most helpful in further narrowing the differential diagnosis?

a. Hb electrophoresis
b. Peripheral blood smear
c. Folic acid and B12 level
d. Total Iron Binding Capacity
e. Occult blood test and Coombs test
3. A 16-year-old boy was referred by his paediatrician for evaluation of persistent anemia.
Two years previously, he presented to his local hospital complaining of fatigue and
weakness. At that point, his hemoglobin level was 4.6 g/dL, with a low mean corpuscular
volume.

Which one of the following is the most likely in the differential diagnosis of this
patient's anemia?

a. Blood loss
b. Hemolysis
c. Fe defficiency
d. Megaloblastic anemia
e. Myelodysplastic syndrome

Which one of the following would be the next best test to narrow the list of differential
diagnoses?

a. Erythropoietin
b. Hb electrophoresis
c. Reticulocyte count
d. Peripheral blood smear
e. Ferritin and Serum iron

If this patient had a low ferritin, which one the most likely diagnosis?

a. Hb varian
b. Thalassemia
c. Fe deficiency anemia
d. Megaloblastic anemia
e. Anemia of chronic disease
 DISKUSI KASUS

1. Seorang perempuan berusia 45 tahun datang ke dokter praktek umum dengan keluhan
merasa mual dan lelah sejak 6 bulan yang lalu dan memberat sejak 2 minggu yang lalu.
Keluhan disertai dengan warna kulit menjadi kuning, sesak napas saat beraktifitas, dan
penurunan berat badan. Tidak ada keluhan sakit perut, nyeri menelan, perubahan
kebiasaan buang air besar, maupun perubahan warna tinja dan urin.
Pada pemeriksaan fisik didapatkan konjungtiva anemis, sclera tidak ikterik, kulit ikterik.
Tekanan darah 120/80 mmHg, denyut nadi 108 x/menit, frekuensi nafas 20 x/menit,
temperatur 36,5 C. Pemeriksaan thoraks dalam batas normal. Pemeriksaan abdomen tidak
ada nyeri tekan, massa ataupun organomegali.
Pada pemeriksaan laboratorium didapatkan kadar Hb 5,2 g/dL, MCV 112 fL, jumlah
leukosit 4.000 / L, jumlah trombosit 131,000 / L, LED 30 mm. Retikulosit 0,5%. Kadar
bilirubin indirek 5,9 mg/dL, tes fungsi hati normal. Tes fungsi Tiroid dan kadar glukosa
puasa normal.

Apa diagnosis yang paling mungkin pada pasien ini?

a. Anemia pasca perdarahan akut

b. Anemia hemolitik
c. Anemia defisiensi Fe
d. Myelodysplastic syndrome
e. Anemia megaloblastik

Apakah pemeriksaan laboratorium lanjutan yang diperlukan untuk menegakkan diagnosis?

a. Hb electrophoresis
b. Sediaan apus darah tepi
c. Kadar asam folat dan B12
d. TIBC
e. Tes darah samar feses dan Coombs tes

Apakah penyebab pansitopenia pada pasien ini ?

a. Supresi sumsum tulang

b. Kekurangan bahan pembentuk hemoglobin
c. Reaksi autoimun
d. Destruksi sel-sel darah di sistem RES
e. Adanya perdarahan

2. Seorang perempuan berusia 23 tahun datang ke puskesmas untuk kontrol evaluasi anemia.
Sejak 6 bulan yang lalu pasien mulai mengalami episode berulang anemia dengan kadar
hemoglobin sekitar 10 g / dL. Tidak ada riwayat mudah memar, menorrhagia, ataupun bukti
nyata pendarahan. Tidak ada perubahan dalam warna urin dan tidak memiliki riwayat
 penyakit kuning. Tidak ada riwayat keluarga anemia atau gangguan hematologi lainnya.
Pada pemeriksaan fisik didapatkan tanda vital pasien normal. Konjungtiva anemis, sclera
tidak ikterik.

Pada pemeriksaan laboratorium didapatkan hemoglobin 9 g / dL (12,0-15,5 g / dL); MCV

94,4 fL (81,6-98,3 fL); hematokrit 13,4% (34,9% -44,5%); jumlah leukosit 6,0 103 / L
(3,5-10,5 103 / uL); dan trombosit 203 103 / uL (150-450 103 / uL).

Apa diagnosis yang paling mungkin pada pasien ini?

a. Anemia pasca perdarahan

b. Anemia Hemolitik
c. Anemia Defisiensi Fe
d. Myelodysplastic syndrome
e. Acquired pure red cell aplasia

Apakah pemeriksaan laboratorium lanjutan yang diperlukan untuk menegakkan diagnosis?

a. Erythropoietin
b. Reticulocyte count
c. Peripheral blood smear
d. Serum iron and ferritin
e. Bone marrow aspiration

Jika didapatkan persentase retikulosit sebesar 13,3%, manakah pemeriksaan

laboratorium lanjutan yang diperlukan untuk menegakkan diagnosis?

a. Hb electrophoresis
b. Peripheral blood smear
c. Folic acid and B12 level
d. Total Iron Binding Capacity
e. Occult blood test and Coombs test

3. Seorang anak laki-laki berusia 6 tahun dibawa ibunya ke praktek dokter umum dengan
keluhan terlihat sangat pucat. Pasien sering mengeluh lekas lelah saat mengikuti aktifitas
di sekolah. Menurut ibunya, pasien sulit makan dan hanya mau makan jajanan warung.

Pada pemeriksaan laboratorium didapatkan hemoglobin 10 g / dL (12,0-15,5 g / dL);

MCV 75 fL, MCH 20 pg, hematokrit 33%, jumlah leukosit 11,0 103 / L, dan trombosit
203 103 / uL.

Apa diagnosis banding yang paling mungkin pada pasien ini?

a. Anemia pasca perdarahan

b. Anemia hemolitik
c. Anemia sekunder karena gangguan fungsi hati
d. Anemia megaloblastik
e. Hemoglobinopati

Apakah pemeriksaan laboratorium lanjutan yang diperlukan untuk menegakkan diagnosis?

a. Erythropoietin
b. Reticulocyte count
c. Peripheral blood smear
d. Serum iron and ferritin
e. Bone marrow aspiration

Jika didapatkan hasil ferritin yang rendah, apakah diagnosis yang paling mungkin ?

a. Hb varian
b. Thalassemia
c. Fe deficiency anemia
d. Megaloblastic anemia
e. Anemia of chronic disease