TUTORIAL REPORT SCENARIO B

“Male in pale”

GROUP XI

Supervisor: dr. Aji Kusuma

Miranda Jamaiyah 702017052

Ega Dwi Putri Koga 702018036

Imam Sandi Pratama 702018048

Ratu Balqis Romadhona 702018090

Putri Saudah Wulandari 702018030

Muhammad Ridho Amrillah 702018080

Sabrina Dwi Annisa 702018061

Shafa Almira 702018097

Rindi Amelia 702018023

Dinda Nafatilana 702018068

MEDICAL SCHOOL

MUHAMMADIYAH PALEMBANG UNIVERSITY

2019

1
 FOREWORD

Thanks God for the grace and gifts so that the authors can complete the
tutorial report entitled "Report of Scenario Case B Scenario Block VIII" as the
task of group competence. Salawat beriring greetings always pour out to our lord,
the great prophet Muhammad and his family, friends, and followers until the end
of time.
The author realizes that this tutorial report is far from perfect. Therefore,
the authors expect criticism and suggestions that are constructive for future
improvement.
In completing this tutorial report, many authors get help, guidance and
suggestions. On this occasion, the author would like to express his respect and
gratitude to:
1. Allah SWT, who has given life with cool faith,
2. Both parents who always provide material and spiritual support,
3. dr. Aji kusuma , as a group tutor 11,
4. Friends in arms.
5. All parties who help writers.
May Allah SWT reward all the charity given to all those who have supported the
author and hopefully this tutorial report is beneficial to us and the development of
science. May we always be in the protection of Allah SWT. Amen.

Palembang, September 2019

                        
 Author

2
 TABLE OF CONTENT

Foreword ..............................................................................................................1
Table of Content ...................................................................................................2
CHAPTER I :
Introduction
1.1 Background ............................................................................3

1.2 Purpose and Advantages ........................................................3

CHAPTER II :
Discussion
2.1 Data Tutorial ..........................................................................4
2.2. Rules .......................................................................................4
2.3 Scenario ..................................................................................5
2.4 Term Classification ................................................................6
2.5 Problem Identification ............................................................6
2.6 Problem Analyz ......................................................................7
2.7 Conclusion ............................................................................28
2.8 Frame Work .........................................................................28

REFERENCES .................................................................................................29

3
 CHAPTER I

PRELIMINARY

1.1. Background
The hematology and lymphatic block is the eighth block in
semester 2 of the Medical Education Competency Based Curriculum in
the Faculty of Medicine, Muhammadiyah University, Palembang. In this
block is taught about which describes cases related to the lymphatic
system of the human body. In addition, as we know that the learning
program in this UMP FK uses KBK learning system, so it is expected
that doctor graduates from FK UMP become doctors who are able to
understand the existing systems in the human body.
On this occasion a scenario case study B was implemented which
presented the case of Mr.Sugiono, a 35 years old scavenger brought to
the internist polyclinic by his family with a chief complain of languid
and frequent tiredness since 2 months ago and worsen on the current
weeks. Mr. Sugiono also complains of frequent headache. Mr. Sugiono
is only able to buy rice, with tempe and tofu. Mr. Sugiono also dislikes
eating vegetables. Mr. Sugiono didn't have any history of worm
infestation, went to malaria endemics area, and getting blood
transfusion. Mr. sugiono didn't have any other medical illnesses.

1.2. Purpose and objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system
at the Faculty of Medicine, Muhammadiyah University of
Palembang.
2. Can solve the case given in the scenario with the method of
analysis and learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 CHAPTER II

DISCUSSION
2.1. Data Tutorial
Mentor : dr. Aji Kusuma
Moderator : Muhammad Ridho Amrillah (7020180)
Secretary Desk : Dinda Nafatilana (702018068)
Secretary Board : Putri Saudah Wulandari (702018030)
Run time : Tuesday, 24 September 2019 (Tutorial stage 1)

Members :

1. Miranda Jamaiyah (702017052)

2. Ega Dwi Putri Koga (702018036)
3. Imam Sandi Pratama (702018048)
4. Ratu Balkis Romadhona (702018090)
5. Sabrina Dwi Annisa (702018061)
6. Shafa Almira (702018097)
7. Rindi Amelia (702018023)

Rules:
1. Switch the phone off or in silence.
2. Raise your hand when going to argument.
3. Permission when going out of the room.
4. Relax and watch as the tutor gives directions.
5. During the tutorial takes care of attitude and speech.

5
2.2. Scenario
" Man In Pale "
Mr. Sugiono, a 35 years old scavenger brought to the internist
polyclinic by his family with a chief complain of languid and frequent
tiredness since 2 months ago and worsen on the current weeks. Mr.
Sugiono also complains of frequent headache. Mr. Sugiono is only able to
buy rice, with tempe and tofu. Mr. Sugiono also dislikes eating vegetables.
Mr. Sugiono didn't have any history of worm infestation, went to
malaria endemics area, and getting blood transfusion. Mr. sugiono didn't
have any other medical illnesses.
Physical Examination:
General Appearance : Looks pale, BP 90/60 mmHg, Pulse 112x/m, RR
20x/m, Temp 36,8C, BH 160 cm, BW 45 kg
Specific examination:
Head: Pale conjungtive (+/+), Atrophy tongue papil (+), icteric sclera (-).
Neck : JVP (5-2) cm H20, Lymph nodes enlargement (-)
Thoraks : Normal cor and pulmo
Abdoment : flat, supple, normal bowel sound, hepar and lien were not
palpable.
Extremity : pale palmar pedis and manus. koilonychia (+)
Laboratory Examination: Blood Chemistry : Hb 8,1 g/dl, RBC
3.800.000/mm2, Leukocyte 8000/mm2, ESR 25 mm/hour, Diff count
0/1/20/58/20/1 Ht 26 l %, reticulocyte 1 %

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 2.3. Clarification of term
1. Headach : Pain in the head.
2. Kollonychia : Distropi of finger nails in which they are
thin and concave , with raise adges
3. Blood tranfution : Blood intake to people who are deficience
in blood.
4. Atrophy tongue papil : Shrinking size of tangue papil cells
5. Reticulocyte : Imature eritrocyte which show the
basophilic reticulum and vital colonias.
6. JVP : Jugular Venous Pressure
7. ESR : Eritrocyte Sedirmentation Rate
8. leukocyte : Cell colorless blood that is able to move
ameboidally, with its main function is to protect the body against
microorganisms that cause disease and can be classified into two main
groups

2.4. Identification of problem

1. Mr. Sugiono, a 35 years old scavenger brought to the internist
polyclinic by his family with a chief complain of languid and
frequent tiredness since 2 months ago and worsen on the current
weeks. Mr. Sugiono also complains of frequent headache.
2. Mr. Sugiono is only able to buy rice, with tempe and tofu. Mr.
Sugiono also dislikes eating vegetables.
3. Mr.Sugiono didn't have any history of worm infestation, went to
malaria endemics area, and getting blood transfusion. Mr. sugiono
didn't have any other medical illnesses.
4. Physical Examination:
General Appearance : Looks pale, BP 90/60 mmHg, Pulse 112x/m,
RR 20x/m, Temp 36,8C, BH 160 cm, BW 45 kg

7
 5. Specific examination:
Head: Pale conjungtive (+/+), Atrophy tongue papil (+), icteric
sclera (-).
Neck : JVP (5-2) cm H20, Lymph nodes enlargement (-)
Thoraks : Normal cor and pulmo
Abdoment : flat, supple, normal bowel sound, hepar and lien
were not palpable.
Extremity : pale palmar pedis and manus. koilonychia (+)
6. Laboratory Examination: Blood Chemistry : Hb 8,1 g/dl, RBC
3.800.000/mm2, Leukocyte 8000/mm2, ESR 25 mm/hour, Diff
count 0/1/20/58/20/1 Ht 26 l %, reticulocyte 1 %.

2.5. Priority of problem

No 1, because the languid, frequent tiredness and headache are the
factors that bring Mr.Sugiono to the Internist polyclinic.

2.6. Analysis of problem

1. Mr. Sugiono, a 35 years old scavenger brought to the internist
polyclinic by his family with a chief complain of languid and
frequent tiredness since 2 months ago and worsen on the current
weeks. Mr. Sugiono also complains of frequent headache.
a. What is the meaning of Mr. Sugiono complain languid and
frequent tiredness since 2 month ago and worsen on the
current weeks, headache?
Answer: The meaning of Mr. Sugiono complain languid and
frequent tiredness since 2 month ago and worsen on the
current weeks and headache is the manifestation of anemia.

b. How is the mechanism of languid, frequent tiredness and

headache?

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 Answer : Dizziness: slight erythrocytes formed + low food
intake (source of Fe) → use of body iron reserves → iron
reserves ↓, continues → bare iron reserves, iron supply for
erythropoesis ↓ → heme formation (protoporfirin IX + Fe2 +)
↓ → globin synthesis disturbed (inhibited by HRI) →
formation of Hb ↓ → low Hb + low erythrocyte count →
transport of O2 to the brain by low erythrocytes → dizziness

c. What is the correlation between Mr. Sugiono age and sex with
complain?
Answer : Mr. Sugiono is a low socio-economic scavenger, low
income is not enough to meet the needs of insufficient
nutritious food intake, in this case iron-containing food needs
are not met complaints (languid, frequent tiredness and
headache). There is a lack of economic factors and low
educational background so that limited knowledge about the
intake of nutritious foods including foods that contain lots of
iron. Low socioeconomic status -> Income that tends to be less
-> fulfillment of nutrient intake (iron) is less -> iron deficiency
anemia (Kartamihardja E, 2008).

d. What is the correlation between Mr.sugiono job as a scavenger

and his main complain ?
Answer : The correlation between Mr.sugiono job as a
scavenger and his main complain is a disease suffered by Mr.
Sugiono is associated with low socioeconomic status such as
malnutrition and low education.

e. What is the anatomy and physiology of RBC?

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Answer: The anatomy and physiology of erythrocyte are:
(Guyton&Hall, 2017).
- Anatomy: erythrocytes are biconcave in shape, which
increases the cell’s surface area and facilitates the
diffusion of oxygen and carbon dioxide. Erythrocyte’s
diameter is 7,8 µm and 2,5 µm thick also 1 µm thick at the
center. Erythrocyte’s volume are 90- 95 µm.

- Physiology of
erythrocyte is to carry
hemoglobin and then the hemoglobin carry oxygen to
organs and tissues.
 Erythropoiesis: pluripotent stem cell → myeloid
progenitor cell → burst forming unit-cell → colony
forming unit → proerythroblast → basophilic
erythroblast → erythroblast polichromatophil →
retuculocyte → erythrocyte
 When erythrocyte are delivered from the bone
marrow into the circulatory system, they normally
circulate for an average of 120 days before being
destroyed. The metabolic system in old erythrocyte is
progressively less active, and causes cells to become
more fragile. Once the erythrocyte’s membrane
becomes fragile, the cell can tear as it passes through
narrow places in the circulation then the cell is carried
to the spleen. Hemoglobin released from cells when

10
 erythrocyte rupture, will soon be phagocyted by
macrophage cells in many parts of the body, but
mainly by liver kupffer cells, splenic macrophages
and bone marrow macrophages. For several hours or
several days after, macrophages will release the iron
obtained from hemoglobin and deliver it back into the
blood and transported by transferrin to the bone
marrow to form new erytrocytes, or to the liver and
other tissues to be stored in the form of ferritin.
Porphyrin part of the hemoglobin molecule is
converted by macrophages through a series of stages
into the bilirubin bile pigment, which is released into
the blood and then excreted from the body by
secretion through the liver into bile

f. What is the possible disease in the case?

Answer: The possible disease in the case are:
1. Anemia
Anemia is a blood disorder. In anemia, our body
doesn’t have enough red blood cells (RBCs). RBCs are
one of the three main types of blood cells. They contain
hemoglobin, a protein that carries oxygen throughout our
body. When we don’t have enough RBCs or the amount of
hemoglobin in our blood is low, our body doesn’t get all
the oxygen it needs. As a result, we may feel tired,
lethargic, tachycardia, shortness of breath, headaches,
dizzy eyes, muscle weakness and coldness in the
extremities (National Institutes Of Health,2011).
The cause of anemia is due to nutritional and non-
nutritional factors. Nutritional factors are related to
deficiency of protein, vitamins, and minerals, while non-

11
 nutritional factors are related to infectious diseases
(Kreamer, 2007).
2. Thalassemia
Thalassemia is a disorder of hemoglobin synthesis
(Hb), specifically the globin chain, which is inherited.
This genetic disease has the most types and frequencies in
the world. Clinical manifestations that arise are varied
from asymptomatic to severe symptoms. The clinical
manifestations of thalassemia are usually the same as
anemia, which is lethargy, fatigue, drowsiness and
shortness of breath (Ganie, 2004).
3. Hypothyroidism
Hypothyroidism is a disease caused by decreased
thyroid hormone function followed by signs and
symptoms that affect the body's metabolic system. The
contributing factor is due to decreased thyroid function,
which can occur congenitally or with age.
Hyperthyroidism has clinical manifestations such as
lethargy, fatigue, drowsiness, headaches and enlargement
of the thyroid gland.

2. Mr. Sugiono is only able to buy rice, with tempe and tofu. Mr.
Sugiono also dislikes eating vegetables.
a. What is the meaning Mr. sugiono is only able to buy rice, with
tempe and tofu Mr. Sugiono also dislikes eating vegetables?
Answer: The possibility that Mr. Sugiono is malnutritions and
didn’t get enough vitamins and minerals that the vegetables
have.

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b. What is the correlation between he able to eating tempe, tofu
and his main complain?
Answer : Monotonous food if consumed continuously will
lead to malnutrition. In food there are macronutrients and
micronutrients that are important for the body. Iron for
example, although it is used in small amounts, its needs are
very important for the formation of Hb. If the need for iron is
reduced, the formation of Hb decreases, which will result in
languid, frequent tiredness and headache.

c. What is the effect Mr. Sugiono dislike eating vegetables?

Answer: The effect is a nutrient deficiency occurs. Because
vegetables contain lots of iron, for example spinach and
broccoli. because iron is useful in the process of
erythropoiesis, if someone is deficient in iron, the body will
use iron reserves so that over time there is a decrease in iron
reserves in the body which will cause various clinical
manifestations of anemia (as experienced by Mr. Sugiono in
this case).

d. How is the nutritional needs for adult?

Answer: The nutritional needs for adult for a day:
1) For a man (20-45 years old)
- Energy : 2800 Kcal
- Protein : 55 gr
- Calcium : 500 mg
- Iron : 1,3 mg
- Vitamin A : 700 mg
- Vitamin E : 10 mg
- Vitamin B : 1,2 mg
- Vitamin C : 60 mg

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 - Folic acid : 70 mg
So, from the case we know that Mr. Sugiono is malnutritions.
We can see it from the food pattern that he eats.

3. Mr.Sugiono didn't have any history of worm infestation, went to

malaria endemics area, and getting blood transfusion. Mr. sugiono
didn't have any other medical illnesses.
a. What is the meaning of Mr. Sugiono didn’t have any history of
worm infestation?
Answer: The meaning of Mr. Sugiono didn’t have any history
of worm infestation is for get rid of the differential diagnosis
of anemia caused by worms.

b. What is the meaning of Mr. Sugiono didn’t have any history of

went to malaria endemics area?
Answer: To deny the differential diagnosis of patients affected
by malaria.

c. What is the meaning of Mr. Sugiono didn’t have any history of

getting blood transfusion?
Answer: The meaning he didn’t getting blood transfusion is
Mr.
Sugiono anemia’s not cause by thalassemia. (mikrositik
hipokrom)

d. What is the meaning of Mr. Sugiono didn’t have any other

medical illnesses?
Answer: Possibility that Mr. Sugiono’s complains isn’t a
symptom of medical illness.

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4. Physical Examination:
General Appearance : Looks pale, BP 90/60 mmHg, Pulse 112x/m,
RR 20x/m, Temp 36,8C, BH 160 cm, BW 45 kg
a. How is the interpretation of physical examination?
Answer: The interpretation of physical examination is:
No Physical Normal In the case Interpretation
. examination

1. Skin Looks pale Abnormal

2. Blood 90-120/60- 90/60 mmHg Normal

Pressure 80mmHg

3. Pulse 60-100x/m 112x/m Tachycardia

4. Respiratory 16-24x/m 20x/m Normal

Rate

5. Temperature 36,5C-37,5C 36,8C Normal

6. Body height Thin: <18 160 Cm BMI= 17,57 (thin,

7. Body weight Normal:18-25 45 Kg underweight)

Fat: 25-27
Obesity:>27

b. How is the mechanism of physical abnormalities?

Answer: The mechanism of physical abnormalities are:
 Pale mechanism: Deficiency of Fe→ erythropoiesis
disorder →blood will flow to more vital organs such as
brain and heart →blood supply to peripheral tissues such
as skin decreases →looks pale (Price, 2014).
 Underweight mechanism: The body needs a balanced
intake of carbohydrate, protein, and fat food. While Mr.

15
 Sugiono only consume rice, tempe and tofu. So that the
adequacy of nutrients needed by the body of Mr. Sugiono.
Not enough lilies. Inadequate nutritional intake can
cause body weight to be below normal (Guyton, 2008).
 Tachycardia: Low food intake (source of Fe) → Hb
formation ↓ → Low hemoglobin + low erythrocyte count
→ body compensation so that blood can remain flowed to
vital organs → Tachycardia

5. Specific examination:
Head: Pale conjungtive (+/+), Atrophy tongue papil (+), icteric
sclera (-).
Neck : JVP (5-2) cm H20, Lymph nodes enlargement (-)
Thoraks : Normal cor and pulmo
Abdoment : flat, supple, normal bowel sound, hepar and lien were
not palpable.
Extremity : pale palmar pedis and manus. koilonychia (+)
a. How is the interpretation of specific examination?
Answer: The interpretation of specific examination is:

No. Specific In the case Interpretation

examination

1. Head Pale conjungtive Abnormal

(+/+)

Atrophy tounge Abnormal

papil (+),

Icteric sclera (-) Normal

2. Neck JVP (5-2) cm H2O Normal

Lymph nodes Normal

enlargement (-)

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3. Thorax Normal cor Normal

Normal pulmo Normal

4. Abdoment Flat, supple, normal Normal

bowel sound

Hepar and lien Normal

were nor palpable

5. Extremity Pale palmar pedis Abnormal

and manus

Koilonychia (+) Abnormal

b. How is the mechanism of specific abnormalities?

answer : The mechanism of specific abnormalities are:
 Pale conjunctiva: The need for Fe is increased and the
intake of Fe is lacking → Fe Reserves ↓ → if the
deficiency persists → Empty Fe reserves → the supply of
Fe for erythropoesis decreases → erythropoesis is
increasingly disrupted → Hb levels ↓ → Transport of
Oxygen to the tissue by erythrocytes ↓ à oxygen is
prioritized to vital organs → vasoconstriction of
peripheral blood vessels in the eye→ Pale Conjunctiva.
 Tongue papilla atrophy: Lack of iron intake → Balance of
Fe decreases → Hb synthesis is disturbed → Fero is
inserted into Protoporfirin IX by inhibitory enzymes
ferocelatase → Synthesis of heme is disturbed →
Biosentesis of globin is inhibited by deficiency through
HRI Heme regulated eIF2alpha kinase (HRI) → Inhibited
factor for initiation of transcription for heme heme
synthesis → Heme and globin chains available for
each RBCd precursor → Hb concentration in the blood
decreases → blood ability to carry oxygen decreases →

17
 oxygen delivery to disturbed tissues → papillary cell
injury → papillary atrophy

6. Laboratory Examination: Blood Chemistry : Hb 8,1 g/dl, RBC

3.800.000/mm2, Leukocyte 8000/mm2, ESR 25 mm/hour, Diff
count 0/1/20/58/20/1 Ht 26 l %, reticulocyte 1 %.
a. How is the interpretation of laboratory examination?
Answer: The interpretation of laboratory examination is:

No Lab Normal In the case Interpretatio

. examinatio n
n

1. Hb 13,5 – 18,0 8,1 gr/dL Anemia

gr/dL

2. RBC 4,6-6,2 sel/L 3.800.000/m Abnormal ↓

m3

3. Leukocyte 5000- 8000/mm3 Normal

10.000/mm3

4. ESR Wintrobe: 0- 25 mm/hour Abnormal ↑

5 mm/h
Westergren:
0-15mm/h

5. Diff count Basophil: 0- 0/1/20/58/20/ Banded N. ↑

1 1 Monocyte ↓
Eosinophil:
0-5
Banded N.:
0-3
Segmented
N.: 40-60
Limfocyte:

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 20-45
Monocyte:2-
6

6. Ht 40-52% 26 vol % Abnormal ↓

7. Reticulocyt 0,6-2,6% 1% Normal

e

b. How is the mechanism of laboratory abnormalities?

Answer: The mechanism of laboratory abnormalities are:
- Anemia, RBC ↓, Ht ↓: Inadequat feeding nutrition →
decreased of iron → decreased of iron supply → keep
happening → bare of iron supply → disturbed of
erytropoiesis → decreased of hemoglobin → anemia →
RBC ↓→ Ht ↓
- ESR ↑: The increase in LEDs is a response to tissue damage
and is a sign of disease. Lack of Fe reserves resulting in
disruption of erythropoesis results in hypoxia in the tissue,
resulting in tissue damage and increased LEDs.
- Diff count: Shift to the right → chronic

c. What is anemia?
Answer: Anemia is a blood disorder. In anemia, our body
doesn’t have enough red blood cells (RBCs). RBCs are one of
the three main types of blood cells. They contain hemoglobin,
a protein that carries oxygen throughout our body. When we
don’t have enough RBCs or the amount of hemoglobin in our
blood is low, our body doesn’t get all the oxygen it needs. As a
result, we may feel tired, lethargic, tachycardia, shortness of
breath, headaches, dizzy eyes, muscle weakness and coldness
in the extremities (National Institutes Of Health,2011). The

19
 cause of anemia is due to nutritional and non-nutritional
factors. Nutritional factors are related to deficiency of protein,
vitamins, and minerals, while non-nutritional factors are
related to infectious diseases (Kreamer, 2007).
d. What is the classification of anemia?
Answer: The classification of anemia are:
1. Pathogenic mechanism (Chulilla et all, 2009).
- Hypo-regenerative: When bone marrow production is
decreased as a result impaired function, decreased
number of precursor cells, reduced bone marrow
infiltration or lack of nutrients
- Regenerative: When bone marrow responds
appropriately to a low erythrocyte mass by increasing
production of erythrocytes.
2. Pathophysiologic classification of anemias (Bakta et all,
2014).
- Anemia due to erythrocyte forming disruption in bone
marrow
a) Lack of essential erythrocyte forming material
1) Iron deficiency anemia
2) Folic acid deficiency anemia
3) Vitamin B12 deficiency anemia
b) Iron utilization disruption
1) Chronic illness anemia
2) Sideroblastic anemia
c) Bone marrow failure
1) Aplastic anemia
2) Myeloptisic anemia
3) Anemia in hematology malignant
4) Diseritropoietic anemia
5) Anemia in myelodisplastic syndrome

20
 6) Decreased eritropoietin anemia: anemia in
chronic ren failure
- Anemia due to hemorrhagic
a) Anemia after acute hemorrhagic
b) Anemia due to chronic hemorrhagic
- Hemolytic anemia
a) Intracorpuscular hemolytic anemia
1) Disruption of erythrocyte membrane
(membranopathy)
2) Disruption of erythrocyte enzyme
(enzymopathy): G6PD deficiency anemia
3) Disruption of hemoglobin
(hemoglobinopathy): thalassemia
4) Structural hemoglobinopathy: HbS, HbE,
etc.
b) Extracorpuscular hemolytic anemia
1) Autoimmune hemolytic anemia
2) Microangiopatic hemolytic anemia
3) etc
- Anemia with unknown causes or with complex
pathogenesis
3. Morphologic and etiology classification of anemias (Bakta
et all, 2014).
- Hypochrome microcyter
a) Iron deficiency anemia
b) Major thalassemia
c) Chronic illness anemia
d) Sideroblastic anemia
- Normochrome normocyter
a) Anemia after acute hemorrhagic
b) Aplastic anemia

21
 c) Acquired hemolytic anemia
d) Chronic illness anemia
e) Anemia in cronic ren failure
f) Anemia in myelodisplastic syndrome
g) Anemia in hematology malignant
- Macrocyter
a) Megaloblastic
1) Folic acid deficiency anemia
2) B12 deficiency anemia, pernicious anemia
b) Non-megaloblastic
1) Anemia in chronic liver disease
2) Anemia in hipotiroidisme
3) Anemia in myelodisplastic syndrome

e. What is the etiology of iron deficiency anemia?

Answer: Major causes of iron deficiency anemia are: (Miller,
2013).
- Blood loss
- Malaria
- Hookworm infections
- Diet and malabsorption of iron

f. What is the epidemiologi iron deficiency anemia?

Answer: Iron deficiency anemia is kind of anemia that often
occurs in developing country. Mortoatmojo et all estimate that
iron deficiency anemia happen to men 16-50% and women
(not pregnant) 25-84%. Pregnant women (46-92%) is the most
susceptible to iron deficiency anemia (Bakta et all, 2014).

g. What is the mechanism of iron deficiency anemia?

22
 Answer: Iron-deficiency anemia may develop because the
body’s demand for iron is greater than its supply, because of
low iron intake or poor iron absorption, or as a result of blood
loss, so that iron reserves are reduced. to be stated as iron
deficiency anemia must go through 3 stages of iron deficiency:

a. First stage
This stage is called iron depletion or store iron deficiency,
characterized by reduced iron reserves or the absence of
iron reserves. Hemoglobin and other iron protein functions
are still normal. In this situation an increase in non-heme
iron absorption. Serum ferritin decreased while other tests
to find out the lack of normal gratitude (Özdemir, 2015).
b. Second stage
This stage is called iron deficient erythropoietin or iron
limited erythropoiesis obtained an insufficient supply of
iron to support erythropoisis. From the results of laboratory
tests, serum iron values decreased and transferrin saturation
decreased, whereas TIBC increased and free erythrocyte
porphrin (FEP) increased (Özdemir, 2015).
c. Third stage
This stage is referred to as iron deficiency anemia. The
condition occurs in the pathway to erythroid bone marrow
is not enough so that it causes a decrease in Hb levels.
From the picture of the edge of the blood obtained
microcytosis and hypochromic progressive. At this stage
there has been a further change in the retail department at
ADB (Özdemir, 2015).

7. How to diagnose?
Answer: To diagnose this case:

23
 - Anamnesis
a. Mr. Sugiono had complain of languid and frequent
tiredness since 2 months ago and worsen on the current
weeks. He also complains of frequent headache.
b. He only able to buy rice with tempe and tofu. He dislikes
eating vegetables.
c. He didn’t have any history of worm infestation, went to
malaria endemics area, and getting blood transfusion. Mr.
Sugiono didn’t have any other medical illnesses.
- General appearance: He looks pale, BP 90/60 mmHg, Pulse
112x/m, BH 160 Cm, BW 45 Kg
- Specific examination: Pale conjungtive (+/+), atrophy tounge
papil (+), pale palmar pedis and manus, koilonychia (+)
- Laboratory examination: Anemia, RBC ↓, ESR ↑, Diff count,
Ht ↓

8. How is the differential diagnosis?

Answer: The differential diagnosis for this case are:
- Iron deficiency anemia
- Folic acid and B12 deficiency anemia (Pernisious anemia)
- Thalassemia

9. What are the additional examination needed to diagnose this case?

Answer: The additional examination needed to diagnose this case
are: (Bakta et all, 2014).
- Blood smear to know about the type of anemia (Iron deficiency
anemia: hipochrome microcyter)
- Counting on the MCV, MCH and MCHC level (Iron
deficiency anemia: MCV <80 fl, MCHC <31%)
- Fe serum/Iron serum, TIBC, Ferritin serum and transferin
saturation. For iron deficiency anemia:

24
 a. Fe serum : <50 mg/dL
b. TIBC : >350 mg/dL
c. Ferritin serum : <20 mg/L
d. Transferin saturation :<15%
- The application of Prussian blue (Perl’s stain) for bone marrow
to evaluate iron storage

10. How is the interpretation of additional examination in this case?

Answer : The interpretation of additional examination in this case
are:

Additional
No. Normal In the case Interpretation
Examination

1. MCV 80 – 100 fl 68 fl Micrositer RBCs

2. MCH 28– 34 pg 21pg Hypochromic RBCs

3. MCHC 32 – 36 32g/dl Normal

g/dL

4. Fe serum 80-180 12 µg/dl Decrease (Iron

µg/dl deficiency)

5. Iron binding 240-450 540 µg/dl Increase (Iron

capacity µg/dl deficiency)

6. ferritin serum 20-250 14 µg/dl Decrease (Iron

µg/dl deficiency)

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7. Bloos smear : Normal Hypochromic Hypochromic
micrositer micrositer

11. How is the mechanism of additional abnormalities?

Answer : The mechanism of additional abnormalities are:
- Mechanism of MCV ↓, MCH ↓, Blood smear : Hypochrome
microcyter: Malnutrition  Decreased of Fe  Fe serum ↓
 Decreased of Fe supply  Ferritin serum ↓  Disturbed of
erythropoises  RBCs ↓  Hb ↓  MCV ↓, MCH ↓ 
Hypochrome microcyter
- Mechanism of Fe serum ↓, Ferritin serum ↓, and TIBC ↑:
Malnutrition  Decreased of Fe  Fe serum ↓  Decreased
of Fe supply  Ferritin serum ↓  Disturbed of
erythropoises  Compensation of hepar  Transferin ↑ 
TIBC ↑

12. What is the working diagnosis of this case?

Answer: Iron deficiency anemia et causa malnutritions.

13. How to treat this case comprehensively?

Answer: To treat this case comprehensively: (Bakta et all, 2014).
- Promotive : Eat healthy food and nutritious food, consuming
vitamin C

26
 - Preventive
a. Health education (environmental health and nutrition
counseling)
b. Eradication of worm infections
c. Iron supplementation
d. Fortification of foodstuffs with iron
- Curative : Iron replacement therapy (oral or parenteral) for 3-
6 months and blood transfusion with PRC (Packed Red Cell)
a. Oral : Ferrous sulphat 3x200 mg , ferrous
gluconat, ferrous fumarat, ferrous lactate and furrous
succinate
b. Parenteral : Iron dextran complex (50 mg/ml), iron
sorbitol citric acid complex, iron ferric gluconate and iron
sucrose
- Rehabilitative : Recheck hemoglobin levels and eliminate
the risk factor such as inadequat feeding nutrition

14. How are the complications?

Answer: Heart failure, tachycardi, arrhythmia

15. How is the prognosis?

Answer: Dubia at bonam
Prognosis is good if the cause of anemia is due to lack of iron
and the cause is known and then adequate treatment is carried out.
Symptoms of anemia and other clinical manifestations will improve

with iron preparations.

16. What is the medical doctor competences in the case?

Answer: Ability 4A: Medical graduates are able to make clinical
diagnoses and manage the disease independently and thoroughly.

27
 17. What is the Islamic point in the case?
Answer: “Eat from whatever is on earth (that is) lawful and good
and don’t follow the footstep of satan. Indeed, he is to you a clear
enemy” (Al-Baqarah 2: 168)

2.7. Hypothesis
Mr. sugiono ,35 years old complain languid, frequent tiredness and
headache due to iron deficiency anemia caused by malnutritions.

2.8. Conceptual framework

Cant buy
Job factor
nutritious food

28
 Cant eat nutritious
food

malnutritions Body nutritional needs 

29
 Decreased of iron
Metabolism 

Decreased of iron
supply Gluconeogenesis 

Disturbed of
Fat and protein 
erythropoiesis

underweight
Iron deficiency
anemia Atrophy tounge papil

koillonychia

Frequent tiredness
Pale conjungtive,
pale palmar pedis languid
and manus
Headache

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