Autoimmune Hemolytic Anemia

Case Report dr. Irwin, Sp. PD Mimi Suhaini bt Sudin 030.08.309

ANAMNESE

ANAMNESE AND AUTO ANAMNESE ON 15th OCTOBER 2012 AT 8 am

IDENTITY
Name Age Sex Mrs T 37 years old Female

Address
Occupation Religion Marital status Date of admission Taken from

Cemara
Housewife Islam Married 14rd October 2012 Rengasdengklok Dormitory

PICTURE OF PATIENT

ANAMNESE
MAIN COMPLAINT
Abdominal discomfort at upper left quadrant since a weeks ago

ADDITIONAL COMPLAINT

Malaise, shortness of breath, headache, pale skin colour

History of present illness

Mrs T came to Emergency Room of RSUD Karawang because of abdominal discomfort at the upper left quadrant since a weeks 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 that her 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.

History of past illness

Same symptom (-) Food and Drug Allergy (-) Malignancy (-) Hypertension (-) Diabetes (-)

Heart Disease (-)

Liver Disease (-)

Asthma (-)

Kidney disease (-)

Family history
Same symptom Hypertension Diabetes

(-) Asthma
(-)

(-) Heart Disease

(-) Malignancy (-)

(-) Liver Disease

(-)

History of treatment
She never been admitted to any hospital before She eats bodrex when ever feels headache

PERSONAL AND SOCIETY HISTORY

Herbal medicine (+)

Blood transfusion (-)

Alcohol (-)

smoking(-)

Vaccination (-)

Physical Examination
General Condition Appearance Consciousness Nutritional status 21.09 kg/cm2
(NORMAL)

: moderately ill : compos mentis : 157cm , 52kg

VITAL SIGN
Blood pressure

Heart rate
80x/m

120/80
Temperature 36.5 C

Respiration rate
20 x / m

PHYSICAL EXAMINATION Head Eyes Ears

Nose Mouth
Anemic conjuctiva +/+ , Icteric sclera -/ Direct and indirect light reflexes +/+

Normocephaly, black-haired and evenly distributed

Normotia, ear secretion -/-, hyperemic -/-, tragus pain -/ Auricula pain -/-, intact tympani membrane +/+ Septum deviation -, hyperemic concha -/-, nasal discharge -/-, nostril breathing Red lip +, dry -, oral hygiene +, pharyngeal arc symetrical, tonsil T1-T1 in normal measure

Neck

Unpalpable lymph node and thyroid, JVP: 5+2 cmH2O

Thorax
INSPECTION
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 in hearts sound

Thorax
INSPECTION

Symmetrical in shape
PALPATION
Equal vocal resonance

PERCUTION
Sonor in both lungs

AUSCULTATION
Vesicular breathing sound in both lung, ronchi -/- , wheezing -/-

Abdominal Examination
INSPECTION 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 (-)

Extremities Examination
WARM ACRALS
+ + +

OEDEM
-

Laboratory Examination (OCTOBER 14

Haematological Parameter Haemoglobin
Leukocyte Trombocyte Haematocryte Blood glucose level Ureum Creatinine

th

2012)

Result
5,9 gr/dl 10000/mm3 283 000 20 % 102 mg/dl 40 mg/dl 0,61 mg/dl

Normal Value
12 17 gr% 5 000 10 000/L 150 000 450 000 37 43 % 80 140 mg/dl 10 45 mg/dl 0,4 1,5 mg/dl

Laboratory Examination (OCTOBER 14

Haematological parameter Basophils Eosinophils Rod Neutrophils Segmen Neutrophils Lymphocytes Monocytes Result
0 0 0 77 19 4

th

2012)

Normal value
(0 1) % (1 - 3) % (2 - 6) % (40 - 70) % (20 - 40) % (2 - 8)%

Laboratory Examination (OCTOBER 15

Haematological Parameter Total Bilirubin Indirect Bilirubin Direct Bilirubin Reticulosit Result 1,12 mg/dl 0,82 mg/dl 0,30 mg/dl 1,7 %

th

2012)

Normal Value <1,1 mg/dl <0,5 mg/dl <0,6 mg/dl 0,5-1,5%

The peripheral blood film (OCTOBER 15th 2012)

Based on the peripheral blood film, the picture of the blood are:
erythrocyte : anisopoichilocytosis polychrome,basophilic stippling (+) , cabot ring (+) Leukocyte : there is no abnormal morfology Trombocyte : there is no abnormal morfology Effect : microcytic anemia

The comb test (OCTOBER 15th 2012)

The comb test is done and the result is positive

Resume
History taking
- 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(-)

Physical examination
- CA +/+ -Pain at epigastrium -Splenomegaly (+),schuffner 5 --dullness (+) at the upper left quadrant

Laboratory findings
-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

DIFFERENTIAL DIAGNOSIS
Iron deficiency anemia Autoimmune hemolytic anemia Lien tumor Malaria

WORKING DIAGNOSIS

AIHA ( Autoimmune hemolytic anemia)

Suggested Examination
Iron serum TIBC USG abdomen

THERAPY
PHARMACOLOGY
- IVFD aminofluid Asering 1:1 - Prednisolon 1mg/kg/day - Sangobion 1x1 NON PHARMACOLOGY - PRC transfusion 3kolf -Suggested to splenectomy

PROGNOSIS

AD VITAM Ad bonam

AD FUNCTIONAM
Dubia Ad bonam

AD SANATIONAM
Dubia ad bonam