Case Report Anak

CASE REPORT
Anemia
Supervisor: dr. Pertin Sianturi, M.Ked(Ped), Sp.A(K)
Presentator: Boris
(110100076)
Try Yudia Ramadhany (110100118)
Department of Pediatric Health
Faculty of Medicine Universitas Sumatera Utara
H. Adam Malik General Hospital
Medan 2015
Literature Review
What is anemia ???
Anemia is a reduction in red cell mass or
Hb and is usually defined as Hb or Hct> 2
standard deviations below the mean for
age.
Physiologic Anemia
Physiologic anemia is the most common cause of anemia
in the neonatal period. Normal physiologic processes often
cause normocytic-normochromic anemia in term and preterm
infants. Physiologic anemia do not generally require extensive
evaluation or treatment.
In term infants, the increase in oxygenation that occurs
with normal breathing after birth causes an abrupt rise in
tissue O 2 level, resulting in negative feedback on
erythropoietin production and erythropoiesis. This reduction in
erythropoietin, as well as the shorter life span of neonatal
RBCs (90 days vs 120 days in adults), causes Hb
concentration to fall over the first 2 to 3 mo of life (typical Hb
nadir 9 to 11 g/dL). Hb remains stable over the next several
weeks and then slowly rises in the 4th to 6th mo secondary to
renewed erythropoietin stimulation.
Etiology
Decreased RBC production
Diagnose
History
Management
Observation and Supportive Care
Case Report
Objective: The
objective of this paper is to report a

case of 3-month old girl with a diagnosis of Anemia.
Name : SJP
Age: 3 months old
Sex: Female
Date of Admission: October 7th 2015
Chief complaint: Prematurity
History of disease:
SJP was reffered from Vina Hospital to Adam Malik General Hospital
to receive adequate treatment. Chief complaint was prematurity and
SJP was admitted to the perinatology department.
History of medication: unclear

History of family: unclear
History of parents medication: Antihypertensive agents
prescribed by obstetrician
History of pregnancy: The mother was 38 years old when
pregnant (G2P2A0). SJP was born with just 30 weeks of
pregnancy. History of hypertension in pregnancy was
found and was treated with anti-hypertensive agents
prescribed by obstetrician. History of diabetes in
pregnancy was dinied.
History of birth: SJP was born in Vina Hospital with only

30 weeks of pregnancy and was helped by obstetrician
via Caesarean method. BW when born is 1000g. BL is
unclear.
History of feeding: Breastfeeded for2 months.
History of immunization: unclear
History of growth and development: unclear
Physical Examination
Present status:
Level of consciousness : CM
Anemic: +
Temperature: 36.8oC
Dyspnea: Localized status:
Crying is loud, sucking is strong.
Head: Eyes : Light reflex (+/+), isochoric pupil, pale
inferior palpebra conjunctiva (+/+).
Ear/ Nose/ Mouth : Normal.
Neck
: Lymph enlargement (-), JVP: R-2cmH2O.
Thorax : Symmetrical fusiform, Chest retraction (-).

HR: 148bpm, regular, murmur (-)
RR: 48x/i, regular, ronchi (-/-), vesicular with no
additional sound.
Abdomen : Soft, non tender, normal peristaltic, liver
and spleen were not palpable, Ascites (-), Tumor (-).
Extremities : Pulse: 148bpm, regular, p/v adequate,
warm acral, CRT<3.
Anogenitalia: Female, Anus (+).
Working diagnosis: Anemia ec chronic disease
+Prematurity.
Further plan: Complete blood check.
Laboratory Findings
Test
Result
Unit
Reference
Hb
8.20
g%
10.7-17.1
RBC
3.07
106/mm3
3.75-4.95
Leucocyte
9.96
103/mm3
6.0-17.5
Thrombocyte
451
103/mm3
217-497
Ht
27.60
38-52
MCV
89.90
fL
93-115
MCH
26.70
pg
29-35
MCHC
29.70
fL
28-34
RDW
20.50
14.9-18.7
Eosinophil
6.7
1-6
Basophil
0.200
0-1
Neutrophil
29.40
37-80
Lymphocyte
49.90
20-40
Monocyte
13.80
2-8
October 7th-8th 2015
Follow Up
Crying is loud, sucking is strong.
Semsorium: CM, Temp: 37.0oC, reflexes are good.

Head: Eyes: Light reflex (+/+), isochoric pupil, pale inferior palpebra
conjunctiva (+/+), Ear-nose-mouth: normal.
Neck: Lymph node enlargement (-), JVP: R-2cmH2O
Thorax: Symmetrical fusiform, Retraction (-).
HR: 148bpm, regular, murmur (-).
RR: 48x/I, regular, ronchi (-/-).
Abdomen: Soft, non tender, peristaltic (+) N, liver and spleen were
not palpable.
Extremities: Pulse 148bpm, regular, p/v adequate, warm acral,
CRT<3
Unproven sepsis
Anemia ec- Chronic Disease
- ABO Incompatibility
- TORCH
- G6PD Defficiency
- Bacterial Infection
Prematurity
Place in incubator with temperature range 36.5-37.5oC

Fluid demand 170cc/BW/day
Parenteral: none
Enteral: 170cc/BW/day
Diet: 15cc/2hrs via OGT
Apialys 1x0.3cc
Ferriz 1x0.3cc
Vitamin E 1x25IU
October 9th 2015

S
Crying is loud, sucking is strong
Sensorium: CM, Temp: 37.3oC, reflexes are good.

conjunctiva (+/+), Ear-nose-mouth: normal
not palpable.
CRT<3
Unproven sepsis
- TORCH
- G6PD Defficiency
Prematurity

Parenteral: none
Apialys 1x0.3cc
Ferriz 1x0.3cc
Vitamin E 1x25IU
Erythropoietin 1 x 0.1cc

S

not palpable.
CRT<3
Unproven sepsis
IUGR (IntraUterine Growth Retardation)
- TORCH
- G6PD Defficiency
Prematurity

Parenteral: none
Apialys 1x0.3cc
Ferriz 1x0.3cc
Vitamin E 1x25IU
Erythropoietin 1 x 0.1cc
Lab findings October 11th 2015
Hb: 8.2g% , RBC: 3.07 x 106, Leu: 9.96 x 103, PLT: 451 x 103, Ht: 27.6%,
MCV: 89.9fL, MCH: 26.7pg, MCHC: 29.7%, Neutrophil: 29.4%,
Lymphocyte: 49.9%, Monocyte: 13.8%, Eosinophil: 6.7%, Basophil: 0.2%

S

Abdomen: Soft, non tender, peristaltic (+) N, liver and spleen were not
palpable.
Extremities: Pulse 148bpm, regular, p/v adequate, warm acral, CRT<3
Unproven sepsis
- TORCH
- G6PD Defficiency
Prematurity

Parenteral: none
Diet: 15cc/2hrs via OGT (OGT aff)
Apialys 1x0.3cc
Ferriz 1x0.3cc
Vitamin E 1x25IU

S

not palpable.
CRT<3
Unproven sepsis
- TORCH
- G6PD Defficiency
Prematurity

Parenteral: none
Apialys 1x0.3cc
Ferriz 1x0.3cc
Vitamin E 1x25IU

S
Crying is loud, sucking is strong, active movement

Abdomen: Soft, non tender, peristaltic (+) N, liver and spleen were not
palpable.
Extremities: Pulse 140bpm, regular, p/v adequate, warm acral, CRT<3
Unproven sepsis
- TORCH
- G6PD Defficiency
Prematurity

Parenteral: none
Apialys 1x0.3cc
Ferriz 1x0.3cc
Vitamin E 1x25IU
Discussion
Theory
Case
Anemia has many causes,

one of those are caused by
decreased RBC production.
This may be caused by
chronic disease, iron
defficiency, poor diet,
infection and also by
prematurity.
In this case, SJP was born

preamaturely at the
gestational age of 30 weeks
and was present with
respiratory distress.
Diagnosing anemia can be

performed by history taking,
physical examination, and
also other diagnostic tests.
In this case, diagnosis of

anemia is done by
performing diagnostic tests
such as complete blood
count.
Theory
Management of anemia
is done by observational
and supportive care,
medication and also iron
therapy if needed.
Case
Observational and
supportive care was
done by placing the
patient in an incubator
with contolled
temperature, feeding
the patient with milk and
keeping the fluid in
balance and also by
giving iron.
Summary
SJP, 3 months old was admitted to H. Adam
Malik General Hospital because of prematurity
and was later diagnosed with + Anemia ec
chronic disease + IUGR + Prematurity and was
treated with supportive care by providing
incubator and feeding and also by giving oral
iron therapy and multivitamin
Apialys 1x0.3cc
Ferriz 1x0.3cc
Vitamin E 1x25IU
THANK
YOU

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CASE REPORT

objective of this paper is to report a

History of medication: unclear

History of birth: SJP was born in Vina Hospital with only

Thorax : Symmetrical fusiform, Chest retraction (-).

October 7th-8th 2015

Crying is loud, sucking is strong.

Semsorium: CM, Temp: 37.0oC, reflexes are good.

Place in incubator with temperature range 36.5-37.5oC

October 9th 2015

Crying is loud, sucking is strong

Sensorium: CM, Temp: 37.3oC, reflexes are good.

Place in incubator with temperature range 36.5-37.5oC

October 10th-11th 2015

Crying is loud, sucking is strong

Sensorium: CM, Temp: 37.1oC, reflexes are good.

Place in incubator with temperature range 36.5-37.5oC

October 12th-14th 2015

Crying is loud, sucking is strong

Sensorium: CM, Temp: 37.1oC, reflexes are good.

Place in incubator with temperature range 36.5-37.5oC

October 15th-18th 2015

Crying is loud, sucking is strong

Sensorium: CM, Temp: 37.1oC, reflexes are good.

Place in incubator with temperature range 36.5-37.5oC

October 19th-21th 2015

Crying is loud, sucking is strong, active movement

Sensorium: CM, Temp: 37.1oC, reflexes are good.

Place in incubator with temperature range 36.5-37.5oC

Anemia has many causes,

In this case, SJP was born

Diagnosing anemia can be

In this case, diagnosis of

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