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    CC 3 April 19 Anemia Combustio

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    Aisya Fikritama
    A 8-year-old boy was admitted with pale skin and weakness. He had a history of iron deficiency anemia and a burn wound on his arm from a year ago. On examination, he appeared pale and undernourished. Laboratory tests confirmed microcytic hypochromic anemia. He was admitted for blood transfusion and dietary supplementation. His burn wound was healing well with dressing changes. Follow up showed improved vital signs and appearance after transfusion.

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    CC 3 April 19 Anemia Combustio

    Uploaded by

    Aisya Fikritama
    28 views35 pages
    A 8-year-old boy was admitted with pale skin and weakness. He had a history of iron deficiency anemia and a burn wound on his arm from a year ago. On examination, he appeared pale and undernourished. Laboratory tests confirmed microcytic hypochromic anemia. He was admitted for blood transfusion and dietary supplementation. His burn wound was healing well with dressing changes. Follow up showed improved vital signs and appearance after transfusion.

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    Cc 3 April 19 Anemia Combustio

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    A 8-year-old boy was admitted with pale skin and weakness. He had a history of iron deficiency anemia and a burn wound on his arm from a year ago. On examination, he appeared pale and undernourished. Laboratory tests confirmed microcytic hypochromic anemia. He was admitted for blood transfusion and dietary supplementation. His burn wound was healing well with dressing changes. Follow up showed improved vital signs and appearance after transfusion.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    28 views35 pages

    CC 3 April 19 Anemia Combustio

    Uploaded by

    Aisya Fikritama
    A 8-year-old boy was admitted with pale skin and weakness. He had a history of iron deficiency anemia and a burn wound on his arm from a year ago. On examination, he appeared pale and undernourished. Laboratory tests confirmed microcytic hypochromic anemia. He was admitted for blood transfusion and dietary supplementation. His burn wound was healing well with dressing changes. Follow up showed improved vital signs and appearance after transfusion.

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    1

    CASE CONFERENCE
    WEDNESDAY MORNING SHIFT,
    RD
    APRIL 3 , 2019

    dr. Ama/ dr. Kiki/ dr. Syahmi/ dr. Labiq/ dr. Anin
    dr. Andrew/ dr. Hamid
    dr. Ismi/ dr. Indra
    2

    PATIENT ADMISSION
    • Melati 2 ward :
    • Child V, 8 yo, 19 kgs with anemia microcytic hypochromic
    due to iron deficiency, combustion region antebrachii
    sinistra, hemithorax sinistra, femoralis sinistra,
    undernourished
    • NICU: -
    • Neonatal HCU: -
    • Wing Mawar 2:
    • Melati 2 HCU:
    • PICU:
    • VIP:
    • Child AD, 1 yo, 8 kgs, with acute diarrhea mild to moderate
    dehydration, well nourished
    3

    PATIENT IDENTITY

    Name :V
    Age/Wt/L : 8 yo/ 19 kgs
    Sex : Male
    Address : Wonogiri, Central Java
    Medical : 01456105
    Record
    4

    CHIEF COMPLAINT
    pale
    5

    THE CURRENT MEDICAL HISTORY

    A week before
    admission
    • Pale (+), weak (+)  patient was brought to RS Amal
    Sehat Wonogiri and had checked lab with Hb 5.8 g/ dl
    referred to RSDM.
    • Rhinorrhea (-), gum bleeding (-), history of bruises (-)
    6

    THE CURRENT MEDICAL HISTORY

    At the ER
    •Patient was fully alert, looked pale, weak (+), bleeding (-),
    • Wound of combustion covered with bandage
    • No fever, no breathlessness
    7

    THE PAST MEDICAL HISTORY

    4 months before admission:


    History of 2 packs PRC transfusion due to Hb 5 
    patient was hospitalized for 2 days

    1 year before admission :


    Combustio because of alcohol burner, got routine
    medication by home care

    History of pulmonary TB and had treated for 6


    months and had fully recovered
    8

    HISTORY OF PREGNANCY AND DELIVERY


    Pregnancy
    The patient is the 1st child of his family. Patient e was born from a 28
    years old mother, G1P0A0, at 40th week of gestational age. His mother
    consumed vitamins from a doctor, not consumed any traditional herbal
    drink. According to the mother, she had routine check her pregnancy to
    the doctor and midwife.

    Delivery
    The patient was delivered by normal labor. There was no complication
    during procedure. The baby cried vigourously, weighted 3000 grams,
    body length 50 cm. The amniotic fluid was clear.

    Conclusion : the pregnancy were normal and the delivery were


    normal
    9

    VACCINATION HISTORY

    0 month : Hepatitis B0
    1 month : BCG, polio 1
    2 months : DPT1, hepatitis B1, polio2
    3 months : DPT2, hepatitis B2, polio3
    4 months : DPT3, hepatitis B3, polio4
    9 months : Measles
    18 months : DPT4, polio 5

    Conclusion :
    complete immunization,
    appropriate with Ministry of Health schedule 2011
    10

    PEDIGREE

    II

    III

    V, 8 yo, 19 kgs
    11

    NUTRITIONAL HISTORY

    Patient eats rice 3 times a day with chicken. Patient does not like meat
    and vegetables. Patient sometimes drinks milk
    Conclusion: nutrition quantity and quality status is
    adequate

    Growth and Development


    GROWTH History
    AND DEVELOPMENT
    Patient is 8 years old now, 19 kgs in body weight, birth
    weight 3000 gram, 50 cm in lenght. The growth and
    developments are normal. Patient could socialize with her
    schoolmate well.
    Conclusion: appropriate for her age
    12

    Nutritional status
    • Body Weight/Age
    19/26x 100% = 73% (underweight)
    • Body Height/Age
    125/129 x 100% = 96 % (normoheight)
    • Body Weight/Body Height
    19/25x 100% = 75% (undernourished)

    Conclusion (CDC 2000) : undernourished,


    underweight, normoheight
    13

    PHYSICAL EXAMINATION
    GA : moderate ill, fully alert, E4V5M6, looked pale
    VS : Heart rate: 106 bpm
    Resp. rate : 25 x/ minutes
    SiO2 : 97%
    Temp: 36.5 oC

    Head : mesocephal
    Eyes : anemic conjunctiva +/+, icteric sclera -/-, isocoric
    pupil (2mm/2mm), light reflex (+/+)
    Nose : nasal flares (-), nasal discharge (-)
    Mouth : cyanosis (-), hyperemic pharynx and tonsil (-)
    Ears : Ear discharge -/-,
    Neck : Lymph node enlargement (-),
    Chest : Symmetrical in shape and movement, retraction (-)
    14

    Cor I : ictus cordis was not visible


    P: ictus cordis was palpable in SIC VI LPSS
    P: cardiac enlargement (-)
    A: 1st 2nd Heart sound normal intensity, regular, no murmur
    Pulmo: I : symmetrical movement (+)
    P: fremitus sounds +/+
    P: sonor +/ sonor +
    A: vesicular breath sounds +/+, additional breath sound (-/-)
    Abd : I : abdominal wall = chest wall
    A : peristaltic sound (+) normal
    P : tympani (+), normal skin turgor
    P : tender, hepar and spleen not palpable
    Extremities : Edema : -/- Cold extremities: -/- Pale -/-
    -/- -/- -/-
    Strong palpable of dorsal pedis artery
    CRT < 2”
    15

    • Localized status :
    • Wound covered with bandage, the wound partially started
    to dry, infiltrate (-), pus (-), blood (-)
    16
    LABORATORY FINDING
    April 3rd, 2019

    Value Reference Units


    Hemoglobin 6.3 11.5-15.5 g/dl
    Hematocrit 22 35-45 %
    Leucocyte 9.9 4.5-14.5 x103/ul
    Thrombocyte 593 150-450 x103/ul
    Erythrocyte 3.73 4.00-5.20 x106/ul
    MCV 59.7 80.0-96.0 /um
    MCH 16.9 28.0-33.0 pg
    MCHC 28.3 33.0-36.0 g/dl
    Neutrophil 77.20 29.00-72.00 %
    Lymphocyte 14.50 30.00-48.00 %
    Monocyte 6.80 0.00-5.00 %
    Eosinophil 1.20 1.00-4.00 %
    Basophil 0.30 0.00-1.00 %

    CONCLUSION:
    Anemia microcytic hipochromic
    17

    PROBLEMS

    A boy, 8 years old, 19 kgs with:

    1. Pale (+)
    2. Weak (+)
    3. History a year before admission  wound of combustion
    covered with bandage because of alcohol burner, got
    routine medication by home care
    4. No fever, no breathlessness
    18

    DIFFERENTIAL DIAGNOSIS

    1. Anemia microcytic hypochromic due to iron deficiency


    dd chronic disease
    2. Combustio grade III (23%)
    3. Undernourished
    19

    WORKING DIAGNOSIS

    1. Anemia microcytic hypochromic due to iron deficiency


    2. Combustio grade III (23%)
    3. Undernourished
    20

    THERAPY
    1. Admitted to Hematooncology subdivision of Pediatric
    2. Diet with food and rice 1500 kcal/day + milk 2x100 ml
    3. D5%1/4 NS 14 ml/ hour
    4. Tranfusion of PRC 380 ml (Hb target 12 g/dl)
    21

    PLAN
    1. CBC, peripheral blood analysis, iron panel, reticulocytes
    2. Consult to Plastic surgery

    MONITORING
     General Appearance/Vital Signs/8 hours
     Balance fluid and diuresis/ 8 hours
    22

    FOLLOW UP
    APRIL 4TH 2019
    23

    PHYSICAL EXAMINATION
    GA : moderate ill, fully alert, E4V5M6, looked pale
    VS : Heart rate: 98 bpm
    Resp. rate : 22 x/ minutes
    SiO2 : 97%
    Temp: 36.5 oC

    Head : mesocephal
    Eyes : anemic conjunctiva +/+, icteric sclera -/-, isocoric
    pupil (2mm/2mm), light reflex (+/+)
    Nose : nasal flares (-), nasal discharge (-)
    Mouth : cyanosis (-), hyperemic pharynx and tonsil (-)
    Ears : Ear discharge -/-,
    Neck : Lymph node enlargement (-),
    Chest : Symmetrical in shape and movement, retraction (-)
    24

    Cor I : ictus cordis was not visible


    P: ictus cordis was palpable in SIC VI LPSS
    P: cardiac enlargement (-)
    A: 1st 2nd Heart sound normal intensity, regular, no murmur
    Pulmo: I : symmetrical movement (+)
    P: fremitus sounds +/+
    P: sonor +/ sonor +
    A: vesicular breath sounds +/+, additional breath sound (-/-)
    Abd : I : abdominal wall = chest wall
    A : peristaltic sound (+) normal
    P : tympani (+), normal skin turgor
    P : tender, hepar and spleen not palpable
    Extremities : Edema : -/- Cold extremities: -/- Pale -/-
    -/- -/- -/-
    Strong palpable of dorsal pedis artery
    CRT < 2”
    25

    • Localized status :
    • Wound covered with bandage, the wound partially started
    to dry, infiltrate (-), pus (-), blood (-)
    26

    WORKING DIAGNOSIS

    1. Anemia microcytic hypochromic due to iron deficiency


    dd chronic disease
    2. Combustio grade III (23%)
    3. Undernourished
    27

    THERAPY
    1. Diet with food and rice 1500 kcal/day + milk 2x100 ml
    2. D5%1/4 NS 14 ml/ hour
    28

    PLAN
    1. CBC, peripheral blood analysis, iron panel, reticulocytes
    2. Consult to Plastic surgery

    MONITORING
     General Appearance/Vital Signs/8 hours
     Balance fluid and diuresis/ 8 hours
    How to transfusion in patient with burn
    injury?

    P • Patient with injury

    I • Restrictive transfusion

    C • Liberal transfusion

    • Mortality, number of infection, LOS, time to


    O healing
    VALIDITY

    Was the assignment of patients to treatments


    randomized?
    • Yes

    Were the groups similar at the start of the


    trial?
    • Yes
    Validity

    A – Aside from the allocated treatment, were


    groups treated equally?
    • Yes only got tranfusions

    Were measures objective or were the patients and


    clinicians kept “blind” to which treatment was being
    received?
    Importancy
    • How large was the treatment effect?
    Applicability

    Is my patient so different to those in the study that the results cannot


    apply?
    • NO

    Is the treatment feasible in my setting?


    • Yes

    Will the potential benefits of treatment outweigh the potential harms of


    treatment for my patient?
    • Yes
    35

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