Summary of Database

Mr. S/67 yo/Bengawan Solo Ward

Autoanamnesis
Chief Complaint:
easy bruising
History of Present Illness:
- The body is easy to bruise since 2 weeks ago, bruises appear suddenly and easily grow when the patient
does hard activities.
- The patient also feels weak easily since the last 2 weeks, and does not improve with rest
- Diagnosed with CML 9 months ago at RSSA from the results of BMP, with the initial complaint being
sudden weakness and was immediately taken to the ER at RSUD Kediri, at RSUD Kediri was suspected of
Leukemia and was given a referral to RSSA, initially routinely taking Hydroxyurea 2x500mg for 2 months
but after BCR -ABL discharged patients routinely consume imatinib 1x400mg, folic acid 1x3mg, vitamin
B12 3x50mcg
- History of hypertension since 1 month ago and routine consumption of Amlodipine 1x10mg
- DM history denied
- BAB and BAK no complaints, Black stool (-), nosebleed (-), bleeding gums (-), hematom (+)
 Summary of Database
Past Medical History:
There was no remarkable past medical history.
Family History:
There was no history of malignancy in the family
Social History:
He lives with his wife and son, he works on building projects
Review of System:
Shortness of breath (-)
Black stool (-), nosebleed (-), bleeding gums (-), hematom (+)
Urination and defecation within normal limit
 Physical Examination
General appearance looked moderate ill Sat O2 99% on RA
GCS 456
BW: 54 kg: H: 160cm: BMI: 21,6 kg/m2

BP 145/79 mmHg PR 94 bpm regular strong RR 18 tpm Tax 36,7 oC

Head Conjuctiva Anemic slightly (+), Sclera Icteric (-),
Neck JVP R+2 cmH20
Chest Symmetrical, retraction (-)

Lung Vesicular | Vesicular Rhonkhi : - | - Wheezing : - | -

Vesicular | Vesiculer -|- -|-

Vesicular | Vesiculer -|- - |-

Cardio Ictus visible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ PSL (D) S1 S2 single, regular, murmur (-) gallop (-)

Abdomen Rounded, Bowel sounds normal, purpura diameter 5x 4 cm, Liver Span 10 cm,
Traube's Space Dullness, Schuffner 3/8

Extremities Warm acral, CRT <2”, Edema superior et inferior (-/-) , purpura diameter 10x 7 cm
elbow sinistra
 Laboratory Findings SIMA (20/12/21)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 2370 4.700 – 11.300 /µL Lab RSSA 17/03/2021
Hemoglobine 6,6 11,4 - 15,1 g/dl
PCV 19% 38 - 42% Blood smear Diff.Count: 8/11/7/9/43/5
Promielosit 6%, Blast cell 11%,
normoblast 9/100 Leucocytes
- Erytrosit : Hypochromic
Anisopoikilocytosis, Cigar cells (+),
Normoblast (+)
-Leucocytes: Impression Quantity
Highly Increase, Neutrophilia (+),
Lymphocytosis (+), Blast Cells (+),
Atypical lymphocytes (+)
-Platelets : Leukocytes Impression
Quantity Increase, Platelet Clumping
(+)
Thrombocyte 11.000 142.000 – 424.000 /µL Lab RSSA 28/09/2021
MCV 75 80-93 fl BCR ABL Kuantitatif
• Average Abl copies : 1,11 x10.3
• Average BCR Abl copies : 9,26
x10.4
• BCR-ABL/ABL (%) 8,34
• BCR-ABL/ABL % (Internasional
Scale) 3753
MCH 26 27-31 pg
Eo/Bas/Neu/ 0/0/ 21/76/3 0-4/0-1/51-67/
Limf/Mon 25-33/2-5
 BMP RSSA (18/03/2021)

CML Chronic Phase with nutritional deficiencies (fe,

folic acid, and/or vitamin B12)
Electrocardiography (21/12/2021)
 Electrocardiography (21/12/2021)
• Sinus rhythm, HR 85 bpm regular
• Frontal Axis : Normal
• Horizontal Axis : Normal
• P wave : 0,04 s
• PR interval : 0,16 s
• QRS complex : 0,08 s
• Q wave : Normal
• QT interval : 0,32s
• ST segment : isoelectric

Conclusion : Sinus rhythm with HR 85 bpm

Chest Xray (08/03/2021)
 Chest X-Ray (08/03/2021)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 50%, shape N, elongation aorta (-), cardiac
waist (+)

Conclusion: normal chest x-ray

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. S/67 yo/Bengawan Solo Ward

1. CML Chronic • Blood - Non-Pharmacologis PMo
Phase smear - Bed rest S, VS, BCR –
S: - Diet TKTP 1800 ABL, CBC
-The body is easy to bruise
- Fatigue kkal/day
- IVFD NaCl 0.9% PEd
-Diagnosed CML since 9 months ago, routinely consume
imatinib 1x400mg, folic acid 1x3mg, vitamin B12
2000 cc/day • Educate the
patient about
3x50mcg Pharmacologis disease,
diagnosis and
O:  PO Imatinib planning
Conjunctiva anemic (+), Splenomegali (Schuffner 3/8), 1x400 mg post
Traube's Space Dullness, purpura (+) poned
Lab :
DL : 6,6 /2370/19%%/11.000

BCL ABL Quantitative

- Average Abl copies : x10.5
- Average BCR Abl copies : x10.5
- BCR-ABL/ABL (%) 8,34
- BCR-ABL/ABL % (Internasional Scale) 3753

Blood smear :
Promielosit 6%, Blast cell 11%, normoblast 9/100
Leucocyt

BMP : CML Chronic Phase with nutritional deficiencies

(fe, folic acid, and/or vitamin B12)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. S/67 yo/Bengawan Solo Ward 2.Trombositopenia - - Non-Pharmacologis PMo

related to CML - Pro transfusion TC 1unit/10 S, VS, CBC
Chronic Phase kgBB/day --> 5 units/day PLT Post
S:
target >= 75000 Transfution
- easy to bruise
- Diagnosed with CML since 9 - Pharmacologis PEd
months ago
O:  Underlying desease • Educate the
patient about
- purpura (+)
disease,
Lab :
diagnosis and
DL : 6,6 /2370/19%%/11.000
planning
BCL ABL Quantitative
- Average Abl copies : x10.5
- Average BCR Abl copies : x10.5
- BCR-ABL/ABL (%) 8,34
- BCR-ABL/ABL % (Internasional
Scale) 3753

Blood smear :
Promielosit 6%, Blast cell 11%,
normoblast 9/100 Leucocyt

BMP : CML Chronic Phase with

nutritional deficiencies (fe, folic acid,
and/or vitamin B12)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. S/67 yo/Bengawan Solo Ward 3. Anemia hypochromic 3.1 related to SI, TIBC, Sat Non-Pharmacologis PMo
malignancy Transferin - Pro transfusion of PRC 2 S, VS, CBC P
3.2 deficiency fe flashs/day up to Hb >= 10 gr/dL Transfution
S:
- fatigue 3.3 Chronic
- Pharmacologis PEd
- Diagnosed with CML since 9 disease
months ago  Underlying desease • Educate the
patient abou
O: disease,
Conjunctiva anemic slightly (+)
diagnosis an
Lab
planning
DL : 6,6 /2370/19%%/11.000
MCV/MCH : 75/ 26
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. S/67 yo/Bengawan Solo Ward 4. Hypertension Non-Pharmacologis PMo

stage I on S, VS, BP
treatment Pharmacologis PEd
S:
• History of hypertension since 1  PO Amlodipin 1x10mg • Educate the
month ago and routine  PO Lisinopril 1x10mg patient about
disease,
consumption of Amlodipine
diagnosis and
1x10mg planning
O:
BP 145/79 mmHg
 Problem Analysis

Risk Factors
Secondary to acute hematopaietic
disorder (MDS, Aplastic anemia) Congenital Familial Environmental Prev chemo agents exposure

CML Thrombocytophenia

Clonal proliferation of hematopoietic

progenitor

Blast infiltration to bone marrow

TKI
Anemia Hypercrome
macrositer
 Risk Factors Analysis

Problem Theory Patient

CML Radiation exposure: Being exposed • Male, 67 yo
to high-dose radiation (such as
being a survivor of an atomic bomb
blast or nuclear reactor accident)
increases the risk of getting CML
Age: The risk of getting CML
increases with age
Gender: This disease is slightly
more common in males than
females, but it's not known why
(cancer.org)
 Key Message Pathophysiology

CML
(Chronic Myeloid Leukimia)

PATOFISIOLOGI
The Ph chromosome is
formed from the
translocation of the ABL
proto-oncogene on
chromosome 9 with the
BCR gene on
chromosome 22 forming
the BCR-ABL protein.
Key Message Pathophysiology
 Key Message Diagnostic

CML PHASE
 Management Analysis

Problem Theory Patient

CML The goal CML treatment is to achieve complete remission • PO Imatinib
Including haematological remission, cytogenetic remission, and even 1x400mg
biomolecular remission

To achieve hematological remission by

using myelosuppressive drugs :

Hydroxyurea
• First choice for hematologic remission induction in CML
• Dose 500-3000 ,h/day to maintain leucocyte 20.000-30.000
• If Leucocyte 20.000-150.000 🡪 50 mg/kgBW/day divided in 2 dose
until leucocyte 20.000
• If >150.000 🡪 need leucopharesys then 20 mg/kgBW/day until
leucocyte 5000-15.000
Busulfan
• Dose 4-8 mg/day p.o, can be increased to 12 mg.day.
• If WBC level too high, give allopurinol and proper hydration
Tyrosine Kinase Inhibitor
• Monoclonal antibody designed to inhibit tirosin kinase inhibitor
• Besides hematologic remission, this drug can give cytogenetic
remission.

Allopurinol
• Allopurinol given as prophylaxis from hyperuricemia : 300 mg/day
Management Analysis
Management Analysis
 Key Message Management

The goals of treatment of chronic myelogenous leukemia

(CML) are:
• Hematologic remission (normal complete blood cell count
(CBC) and physical examination (ie, no organomegaly)
• Cytogenetic remission (normal chromosome returns with
0% Philadelphia chromosome–positive (Ph+) cells)
• Molecular remission (negative polymerase chain reaction
[PCR] result for the mutational BCR/ABL mRNA), which
represents an attempt for cure and prolongation of patient
survival
 Key Message Management

Table 4 Milestones for treating CML expressed as BCR-ABL1 on the International Scale
(IS).

 
European LeukemiaNet 2020 recommendations for treating chronic myeloid leukemia
 Key Message Social

• Patient and family should be informed about the

disease prognosis and progressive possibility to
malignancies
• Nutritional support is an important non-
pharmacology treatment in patient. It could be
achieved by family supports and closely follow-up
 Condition This Morning

• GCS 456
• BP : 138 mmHg
• HR : 95bpm
• RR : 20tpm
• Tax : 36,5 C
 Prognosis

• Ad vitam : Dubia
• Ad functionam : Dubia
• Ad sanationam : Dubia
Thank You