CASE CONFERENCE

June 2 2018
nd

Morning shift
 PATIENT ADMISSION
MELATI 2 WARD:
AZ, 6 y.o, 37 kgs, neutropenia fever, acute
rhinopharingitis, osteosarcoma on chemotheraphy,
overnourished

HCU NEONATUS :
N, 1 days, 3800 grams. consulted by surgery with Atresia ani with
enterocutan fistel, neonatal sepsis, breathlessness due to
pneumonia, neonate, boy, normal birth weight, full term,
appropriate to gestational age, spontaneous outside delivery
PICU : (-)
HCU MELATI 2 : (-)
NICU : (-)
2
 3
PATIENT IDENTITY

Name : AZ
Age : 6 years old
Gender : Female
W/ L : 38 kg, 116 cm
Address : Sungai Liat, Bangka
MR : 01419642
 4

Chief Complaint :
Fever
 5

8 Days before admission

• Patient was discharged from Moewardi
• Patient was admitted for osteosarcoma
• Patient undergone chemotherapy (1st cycle)
• When discharged : fever (-), nausea (-), intake
(+)
• Normal urination & defecation
 6

4 Days before admission

• Patient had cold and was given cetirizine
• Fever (-), intake (+), cough (-)
• Normal urination & defecation
 7

2 Days before admission

• Patient had gradually increasing Fever (+) up to
38,1 oC
• Patient was given paracetamol. The fever
subsides but return again
• Cold (+), cough (-)
• Defecation 1x, yellow, soft
• Normal urination, clear color
• Ear discharge (-)
• Paracetamol was given but fever still present
 8

Admission day
• Patient still had Fever (+), Cold (+), cough (-),
nausea (-), vomiting (-)
• Patient was given paracetamol at 12pm
 9

AT THE ER
• Patient was fully alert, Fever (+), Cold (+), cough
(-), nausea (-), vomiting (-)
• Intake (+)
• Defecation & urination are normal
• Epistaxis (-), bleeding gum (-), bruises (-)
 10

PAST MEDICAL HISTORY

• History of past illness: Patient is a routine
hematology oncology patient with osteosarcoma
undergone 1st week of chemotherapy
 11

Family Medical History

• History of malignancy : (-)
 12

Pregnancy and Delivery History

• During pregnancy, mother routinely checked her
pregnancy to doctor. She was given vitamins, and didn’t
consume any other of medicine. No history of
hospitalization during pregnancy
• Baby was born at full term pregnancy, normal delivery,
cried vigorously, no cyanosis or icteric was found and his
birth weight was 2600 grams and the length was 48 cm

Conclusion: normal birth history and normal pregnancy

 13

Vaccination History
Basic
• Hep B : 0 month
• Polio : 1,2,3,4 month
• BCG : 1 month
• DPT, Hib, HepB : 2,3,4 month
• Measles : 9 month

Booster :
• 18 months : Measles, DPT, HB, Hib

Conclusion : Complete basic and booster immunization according to

Ministry of Health’s schedule
 14

Nutrition Growth and

History
• Patient eats rice and side
dish, drinks water and
milk 3-4 times a day
Development
• She is now 6 years old
and able to do activities
like his friend
• Her weight is 38 kg and
her height is 116 cm

Conclusion: normal
Conclusion : quality and
quantity of nutrition are growth and
development
adequate
 15

Nutritional Status
CDC
• Weight for Age : 25%< WFA < 50% normoweight
• Length for Age: 25% < HFA < 50% normoheight
• Weight for length: 38/21x100% = 180% over
nourished

Conclusion: normoheight, normoweight, overnnourished

 16

Pedigree
I

II

III

AZ, 6 years old

 17

Physical Examination
General appearance:
Moderately ill, fully alert

Vital Signs:
1. Heart rate: 140 bpm
2. Body temperature : 37,80C
3. Respiration rate: 24 x/min
4. Oxygen Saturation: 99%
 18

Physical Examination
• Head : Mecocephalic
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic (+/+), icteric (-/-)
• Nose : Discharge (+), nasal flare (+)
• Mouth : wet mucosa (+), T3-T3, hyperemia (-)
• Ear : discharge (-/-)
• Neck : lymph nodes enlargement (-)
• Chest : symmetric, no retraction

LUNG:
• I: normal, symmetric, no
retraction, floating rib (-
/-)
• P: left =right
• P: sonor in both lung
• A: vesicular breath sound
(+/+), additional breath
sound (-/-), Ronchi (-/-),
wheezing (-/-)
19
CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis not
palpable
• P: there is no cardiac
enlargement
• A: 1st 2nd Heart sound
intensity is normal,
regular, murmur (-)

ABDOMEN
• I: abdominal wall =
thorax wall
• A: peristaltic sound (+)
normal
• P: tympanic (+)
• P: hepatosplenomegaly
(-), soft, tenderness (-)
20
EXTREMITIES:
• CRT < 2 seconds,
• Dorsalis Pedis artery
strongly palpable
• Warm extremities
• Palpable mass on
upper left arm
 21

Laboratory Findings (June 2nd 2018)

Value Reference Units

Hemoglobin 9,2 10.8-15.6 g/dl
Hematocrit 27 33-45 %
Leucocyte 4,8 4.5-14.5 x103/ul
Thrombocyte 184 150-450 x103/ul
Erythrocyte 3,36 3.8-5.8 x106/ul
/um
MCV 79,8 80.0-96
28.0-33.0 Pg
MCH 27,4
33.0-36.0 g/dl
MCHC 34,3
11.6-14.6 %
RDW 11,8
7,2-11,1 Fl
MPV 10,1
25-65 %
PDW 10
 22

Value Reference Units

Eosinophil 0,00 0.00-1.00 %

Basophil 0,20 18.00-74.00 %

Netrophil 30,50 60.00-66.00 %

Lymphocyte 54,00 0.00-6.00 %

Monocyte 15,30 0.00-1.00 %

ANC : 1464

Conclusion : Microcytic hypochromic anemia, neutropenia,

lymphocytosis, monocytosis
 23

FNAB (April 27th 2018)

• Clinical Diagnosis : suspected osteosarcoma
on upper left arm
• Sample : FNAB on upper left arm

Result : Atypical cells

 24

PA (May 2nd 2018)

• Clinical Diagnosis : suspected osteosarcoma
on upper left arm
• Sample : upper left arm, 2 slice, 2x0,8x0,5 cm

Result : Osteosarcoma
 25

Problem List
AZ, female, 6 years old, 38 kgs with :
• Patient was discharged from Moewardi after chemo (1st
cycle)
• When discharged : fever (-), nausea (-), intake (+),
Normal urination & defecation
• Patient had cold 4 days later
• Fever (+) 38,1 oC and was given paracetamol, cough (-)
• At the ER patient was fully alert, Fever (+), Cold (+),
cough (-), nausea (-), vomiting (-)
• Epistaxis (-), bleeding gum (-), bruises (-)
 26

Problem List
Physical exam
1. Anemic (+/+) conjunctivae
2. T3-T3 tonsils
3. Tumor on upper left arm

Lab findings
1. Microcytic hypochromic anemia
2. Neutropenia
3. Lymphocytosis
4. Monocytosis
5. PA : Atypical cells, osteosarcoma
 27

Differential Diagnosis
1. Febrile observation due to suspected neutropenia
fever dd UTI
2. rhinopharingitis
3. Osteosarcoma in first cycle chemotherapy
 28

Working Diagnosis
1. Neutropenia fever
2. Rhinopharyngitis
3. Osteosarcoma in first cycle chemotherapy
4. Overnourished
 29

Therapy
1. Admitted to pediatric hemato-oncology
2. Rice and side dish diet 1800 kkal/day
3. IVFD D5 ½ NS 63 ml/hr IV
4. Paracetamol (15mg/kg/8h) ~ 500mg/8h
5. Cetirizine 5mg/24h
6. Amoxicillin clavulanate inj (15 mg/kg/8h) ~
600mg/8h IV
 30

Plan Monitoring
• CBC • General appearance/Vital
• Urinalysis signs/Saturation/8 hours
• Routine feces
• Fluid balance &
diuresis/8hr
 31

FOLLOW UP
 32

FOLLOW UP (June 3rd 2018)

S:
Fever (+), Cold (+), cough (-), nausea (-), vomiting (-), epistaxis
(-), bleeding gum (-), bruises (-)

O:
General appearance:
Moderately ill, fully alert

Vital Signs:
1. Heart rate: 140 bpm
2. Body temperature : 37,80C
3. Respiration rate: 24 x/min
4. Oxygen Saturation: 99%
 33

Physical Examination
• Head : Mecocephalic
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic (+/+), icteric (-/-)
• Nose : Discharge (+), nasal flare (+)
• Mouth : wet mucosa (+), T3-T3, hyperemia (-)
• Ear : discharge (-/-)
• Neck : lymph nodes enlargement (-)
• Chest : symmetric, no retraction

LUNG:
• I: normal, symmetric, no
retraction, floating rib (-
/-)
• P: left =right
• P: sonor in both lung
• A: vesicular breath sound
(+/+), additional breath
sound (-/-), Ronchi (-/-),
wheezing (-/-)
34
CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis not
palpable
• P: there is no cardiac
enlargement
• A: 1st 2nd Heart sound
intensity is normal,
regular, murmur (-)

ABDOMEN
• I: abdominal wall =
thorax wall
• A: peristaltic sound (+)
normal
• P: tympanic (+)
• P: hepatosplenomegaly
(-), soft, tenderness (-)
35
EXTREMITIES:
• CRT < 2 seconds,
• Dorsalis Pedis artery
strongly palpable
• Warm extremities
• Palpable mass on
upper left arm
 36

Differential Diagnosis
1. Febrile observation due to suspected neutropenia
fever dd UTI
2. rhinopharingitis
3. Osteosarcoma in first cycle chemotherapy
 37

Working Diagnosis
1. Neutropenia fever
2. Rhinopharyngitis
3. Osteosarcoma in first cycle chemotherapy
4. Overnourished
 38

Therapy
1. Admitted to pediatric hemato-oncology
2. Rice and side dish diet 1800 kkal/day
3. IVFD D5 ½ NS 63 ml/hr IV
4. Paracetamol (15mg/kg/8h) ~ 500mg/8h
5. Cetirizine 5mg/24h
6. Amoxicillin clavulanate inj (15 mg/kg/8h) ~
600mg/8h IV
 39

Plan Monitoring
• CBC • General appearance/Vital
• Urinalysis signs/Saturation/8 hours
• Routine feces
• Fluid balance &
diuresis/8hr
 40

FOLLOW UP (June 4th 2018)

S:
Fever (-), Cold (+), cough (-), nausea (-), vomiting (-), epistaxis (-
), bleeding gum (-), bruises (-)

O:
General appearance:
Moderately ill, fully alert

Vital Signs:
1. Heart rate: 120 bpm
2. Body temperature : 37,20C
3. Respiration rate: 24 x/min
4. Oxygen Saturation: 99%
 41

Physical Examination
• Head : Mecocephalic
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic (+/+), icteric (-/-)
• Nose : Discharge (+), nasal flare (+)
• Mouth : wet mucosa (+), T3-T3, hyperemia (-)
• Ear : discharge (-/-)
• Neck : lymph nodes enlargement (-)
• Chest : symmetric, no retraction

LUNG:
• I: normal, symmetric, no
retraction, floating rib (-
/-)
• P: left =right
• P: sonor in both lung
• A: vesicular breath sound
(+/+), additional breath
sound (-/-), Ronchi (-/-),
wheezing (-/-)
42
CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis not
palpable
• P: there is no cardiac
enlargement
• A: 1st 2nd Heart sound
intensity is normal,
regular, murmur (-)

ABDOMEN
• I: abdominal wall =
thorax wall
• A: peristaltic sound (+)
normal
• P: tympanic (+)
• P: hepatosplenomegaly
(-), soft, tenderness (-)
43
EXTREMITIES:
• CRT < 2 seconds,
• Dorsalis Pedis artery
strongly palpable
• Warm extremities
• Palpable mass on
upper left arm
 44

Differential Diagnosis
1. Febrile observation due to suspected neutropenia
fever dd UTI
2. rhinopharingitis
3. Osteosarcoma in first cycle chemotherapy
 45

Working Diagnosis
1. Neutropenia fever
2. Rhinopharyngitis
3. Osteosarcoma in first cycle chemotherapy
4. Overnourished
 46

Therapy
1. Admitted to pediatric hemato-oncology
2. Rice and side dish diet 1800 kkal/day
3. IVFD D5 ½ NS 63 ml/hr IV
4. Paracetamol (15mg/kg/8h) ~ 500mg/8h
5. Cetirizine 5mg/24h
6. Amoxicillin clavulanate inj (15 mg/kg/8h) ~
600mg/8h IV
 47

Plan Monitoring
• CBC • General appearance/Vital
• Urinalysis signs/Saturation/8 hours
• Routine feces
• Fluid balance &
diuresis/8hr
48