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Arifin 29 Mei. AIHA

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1 Maryanis/Female/56YO/FW 04

Chief Complaint
Fatigue and weakness since 1 week ago.

Present Illness History


• Fatigue and weakness increased since 1 week ago.
• Looked pale since 1 week ago.
• Looked yellowish on skin since 1 week ago
• There is no cough, breathlessness, and fever
• There in no history of gums bleeding, nosebleed, or black vomit
• Defecation is normal, no black defecation
• Micturition is normal
• Patient had been known as AIHA since 2016. Patient had been
hospitalized at RSUP M.Djamil Padang in September 2021, treated
with Methylprednisolone 3x16mg, Lansoprazol 1x30mg and Osteocal
1x1000mg, got blood transfusion.
Past Illness History
• No history of hypertension and DM type II
• PTCA in 2016 due to myocardial infarction, treated with
Nitral and aspilet, last control was September 2021

Family Illness History


• No family members suffer from the same complaint
Physical Examination VII

• General Appearance : Moderate

• Consciousness level : Compos Mentis Cooperative

• BP : 130/70 mmHg

• HR : 92x/minute

• RR : 18 x/minute

• T : 37,2 C

• SpO2 : 99%
• Eye VII
– Conjunctiva anemic (+/+)
– Icteric sclera(+/+)
• Neck
– JVP 5+0 cmH20
• Lung: normochest
– Inspection: symmetric right = left
– Palpation: fremitus right = left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger lateral LMCS ICS VI
– Percussion:
• Left border: 1 finger lateral LMCS ICS VI
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-), gallops (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and spleen are not palpated
– Percussion: tympani
– Auscultation: bowel sound (+) normal

• Extremities:
– Oedema -/-
Laboratory
Items Value VII
Hb 5,2 gr/dl
Ht 14%
Leukosit 5.880/mm3
Platelet 129.000/mm3
Reticulosit 22,61
Diff. Count (B/E/NB/NS/L/M) 0/1/4/65/14/10

SGOT/SGPT 38/11

PT/APTT 11,4/22,2

Ur/Cr 22/1
Na/K/Cl 138/3,6/107
RBG 106
Chest X-Ray VII
ECG VII
Problems

• Anemia
• Cardiomegaly
• PVC infrequent
Working Diagnosis

• Severe anemia normocytic normochrome ec AIHA


• CAD Post PTCA
• PVC infrequent
Therapy
• Rest/ reguler diet high calory high protein
• IVFD Nacl 0,9% 8 hours/kolf
• Folic acid 1x 1mg po
• Vitamin B complex 1x1 tab po
• Methyprednisolone 3x16mg po
• Lansoprazol 1x30mg po
• Osteocal 1x1000mg po
• WRC transfusion 2 unit
Plan
• Urinalysis

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