AIHA Case Dr Irwin

7/30/2019 AIHA Case Dr Irwin

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Autoimmune Hemolytic Anemia

Case Report

dr. Irwin, Sp. PD

Mimi Suhaini bt Sudin

030.08.309


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ANAMNESE

ANAMNESE AND AUTO ANAMNESE ON

15th OCTOBER 2012 AT 8 am


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IDENTITY

Name Mrs T

Age 37 years old

Sex Female

Address Cemara

Occupation Housewife

Religion Islam

Marital status MarriedDate of admission 14rd October 2012

Taken from Rengasdengklok Dormitory


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PICTURE OF PATIENT


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ANAMNESE

Abdominal discomfort atupper left quadrant sincea weeks ago

MAINCOMPLAINT

Malaise, shortness of

breath, headache, paleskin colourADDITIONAL

COMPLAINT


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History of present illnessMrs T came to Emergency Room of RSUD Karawang because

of abdominal discomfort at the upper left quadrant since aweeks 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 thather 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.


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History of past illness

Same symptom

(-)

Hypertension

(-)

Diabetes

(-)

Food and DrugAllergy

(-)

Heart Disease

(-)

Liver Disease

(-)

Malignancy

(-)

Asthma

(-)

Kidney disease

(-)


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Family history

Same symptom

(-)

Hypertension

(-)

Diabetes

(-)

Asthma

(-)

Heart Disease

(-)

Liver Disease

(-)

Malignancy

(-)


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History of treatment

She never been admitted to any hospital before

She eats bodrex when ever feels headache


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PERSONAL AND SOCIETY HISTORY

Herbal medicine (+)

Blood transfusion (-)

Alcohol (-)Vaccination

(-)

smoking(-)


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Physical Examination

General Condition

Appearance : moderately ill

Consciousness : compos mentis

Nutritional status : 157cm , 52kg

21.09 kg/cm2(NORMAL)


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VITAL SIGN

Blood pressure

120/80

Heart rate

80x/m

Temperature

36.5 C

Respiration rate

20 x / m


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PHYSICAL EXAMINATION

Normocephaly, black-haired and evenly distributedHead Anemic conjuctiva +/+, Icteric sclera -/-

Direct and indirect light reflexes +/+Eyes

Normotia, ear secretion -/-, hyperemic -/-, tragus pain -/- Auricula pain -/-, intact tympani membrane +/+Ears

Nose

Mouth

Neck

Septum deviation -, hyperemic concha -/-, nasal

discharge -/-, nostril breathing -

Red lip +, dry -, oral hygiene +, pharyngeal arc

symetrical, tonsil T1-T1 in normal measure

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


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ThoraxINSPECTION

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 inhearts sound


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Thorax

INSPECTION

Symmetrical in shape

PALPATION Equal vocal resonance

PERCUTION

Sonor in both lungs

AUSCULTATION

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


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Abdominal ExaminationINSPECTION

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 (-)


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Extremities Examination

WARM

ACRALS

+ +

+ +OEDEM

- -

- -


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Laboratory Examination (OCTOBER 14th 2012)

Haematological

Parameter

Result Normal Value

Haemoglobin 5,9 gr/dl 12 17 gr%

Leukocyte 10000/mm3

5 000

10 000/LTrombocyte 283 000 150 000 450 000

Haematocryte 20 % 37 43 %

Blood glucose level 102 mg/dl 80 140 mg/dl

Ureum 40 mg/dl 10 45 mg/dl

Creatinine 0,61 mg/dl 0,4 1,5 mg/dl


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Haematological

parameter

Result Normal value

Basophils 0 (0 1) %Eosinophils 0 (1 - 3) %

Rod Neutrophils 0 (2 - 6) %

Segmen Neutrophils 77 (40 - 70) %Lymphocytes 19 (20 - 40) %

Monocytes 4 (2 - 8)%


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Haematological

Parameter

Result Normal Value

Total Bilirubin 1,12 mg/dl


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The peripheral blood film (OCTOBER 15th 2012)

Based on the peripheral blood film, the picture of

the blood are:

erythrocyte : anisopoichilocytosispolychrome,basophilic stippling (+) , cabot ring (+)

Leukocyte : there is no abnormal morfology

Trombocyte : there is no abnormal morfology

Effect : microcytic anemia


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The comb test (OCTOBER 15th 2012)

The comb test is done and the

result is positive


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- 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(-)

- CA +/+

-Pain at epigastrium

-Splenomegaly

(+),schuffner 5

--dullness (+) at theupper left quadrant

-

-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

ResumeHistory taking Physical

examinationLaboratory

findings


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DIFFERENTIAL DIAGNOSIS

Iron deficiency anemia

Autoimmune hemolytic anemia

Lien tumor Malaria


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WORKING DIAGNOSIS

AIHA ( Autoimmune hemolytic anemia)


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Suggested Examination

Iron serum

TIBC

USG abdomen


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THERAPY

PHARMACOLOGY

- IVFD aminofluid Asering 1:1

- Prednisolon 1mg/kg/day- Sangobion 1x1

NON

PHARMACOLOGY

- PRC transfusion 3kolf

-Suggested to

splenectomy


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PROGNOSIS

AD VITAM

Ad bonam

ADFUNCTIONAM

Dubia Adbonam

ADSANATIONAM

Dubia adbonam


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Documents

AIHA Case Dr Irwin