dr.

Vidi

MORNING REPORT
Date : Wednesday 23/02/2021
Physician in charge
I Ikutan : dr. Iraky, dr. Satiti, dr. Fahri
I : dr. Madya, dr. Agnes, dr. Vidi
II Consult : dr. Firman
II HCU : dr. Mazen
II Incovit : dr. Sandi
II ER Incovit : dr. Ferdi
II UGD : dr. Hani, dr. Haris
Chief on duty : dr. Ajeng
Consultant on duty : dr. Laksmi Sasiarini, Sp.PD-KEMD
Facilitator : dr. Laksmi Sasiarini, Sp.PD-KEMD
 Summary of Database
Mr. AB / 48.y.o/Ward 27 Bed 16
Autoanamnesa
Chief Complaint:
Fatigue
History of Present Illness:
The patient was admitted to the hospital from the HOM clinic for leukopharesis. Currently, the
patient complained easily felt fatigue worsening since 3 days ago, accompanied with shortness of breath.
Shortness of breath was not relieve with rest. Patient also complained of intermitten fever since 3 days
ago without history of cough.
He was just discharged from the hospital two weeks ago, had been done leucopharesis last
admission because he still had high level of white blood counts (> 200.000)
He was diagnosed with CML since 6 years ago, routinely consumed Tasigna 2x400 mg since 2019.
Patient didn’t consumed tasigna since 5 days ago, because he didn’t go to hospital to took his regular
drug. Actually he also ever had Hydroxyurea, but had already stopped since a month
 Summary of Database
Past Medical History:
He was hospitalize for a few times, because of he need PRC transfusion and leucopharesis
Family History:
His Father had hypertension. None of his family had a history of malignancy, chronic disease,
such as DM. His grandfather and grandmother were passed away but he didn’t know what was the
cause.
Social History:
Patient is an unemployee, the daily activities mostly spent in his home, married, and has 2
children.
Review of System:
General: fatigue (+) weight loss (+) 3 kg for the last 3 months
Skin: within normal limit
Head and neck: within normal limit
Respiratory: shortness of breath (+)
Gastrointestinal: abdomen felt hard
Extremities: palms looked pale
 Physical Examination
General appearance looked moderately ill VAS 0/10
GCS 456 Compos Mentis, KS 80% BW 50 kg; BH 160 cm; BMI 19,5 kg/m2
BP 97/56 mmHg PR 89 bpm regular strong RR 24 tpm Tax 36,4 oC Sat O2 99% on NC
4lpm
Head Anemic Conjuctiva (+)
Neck JVP R+ 2 cmH20 30 degrees, enlargement lymph nodes (-)
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular| Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular| Vesicular
-| - -|-
Sonor | Sonor Vesicular| Vesicular
+| - - |-
Cardio Ictus invisible, palpable at ICS V MCL (S)
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Flat, soefl, Bowel Sound (+) normal

Liver/ liver span 12 cm, epigastrium tenderness (-)
Lien traubes space dullness, schuffner 6/8
Extremities Edema (-) , MMT 5 | 5 , looked pale (+)
5|5
Laboratory Findings (23/3/2021)
LAB VALUE NORMAL

Hb 4.3 11,4 - 15,1 g/dl

Leucocyte 494.870 4.700 – 11.300 /µL

PCV 11.70% 38 - 42%

Thrombocyte 254.000 142.000 – 424.000

/µL

Eo/Bas/Neu/ 0.6/1.1/74.1/ 0-4/0-1/51-67/

Limf/Mon 17.4/6.8% 25-33/2-5

MCV 92.90 fl 80-93 fL

MCH 34.1 pg 23-71 pg

ANC 366.350

Monocyte 33.820

Rapid antigen SARS Negatif Negatif

Cov-2
 Laboratory Findings (23/03/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Hb 4.3 11,4 - 15,1 g/dl Ureum 35.3 20-40 mg/dL

Leucocyte 494.870 4.700 – 11.300 /µL Creatinine 1.34 <1,2 mg/dL

PCV 11.70% 38 - 42% GFR 62.2 >90 mL/min/1.73

m2
Thrombocyte 254.000 142.000 – 424.000 /µL Natrium 135 136-145 mmol/L

Eo/Bas/Neu/ 0.6/1.1/74.1 0-4/0-1/51-67/ Kalium 6,03 3,5-5,0 mmol/L

Limf/Mon /17.4/6.8% 25-33/2-5
MCV 92.90 fl 80-93 fL Chlorida 101 98-106 mmol/L

MCH 34.1 pg 23-71 pg Calcium 8,8 7,6-11,0 mg/dL

ANC 366.350 Phosfor 4,0 2,7-4,5 mg/dL

Monocyte 33.820 Uric acid 9,2 3,4-7,0 mg/dL

Rapid antigen SARS Negatif Negatif

Cov-2
 Blood Smear (23/3/2021)

Erythrocytes: Normochrome anisopoikilocytosis,

polychromation (+), elliptocytes (+)
Leucocytes: The impression of the number is
greatly increased, cell blast (+)
Platelets: normal count
Blood Smear (23/3/2021)
BCR ABL Quantitative 13/8/2019

• Average ABL 1.28 106

• Average BCR-ABL 3.69 x 105
• BCR ABL/ABL 28.3%
Electrocardiography (23/3/2021)
 Electrocardiography (23/3/2021)
• Sinus rhythm, HR 86 bpm regular
• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : normal
• PR interval : 0.12”
• QRS complex : 0.10”
• Q wave : no pathological Q
• QT interval : 0.40”
• ST segment : isoelectric

Conclusion : Sinus Rhythm with HR 86 bpm

KHORANA Score for VTE

Patient’s Score:
2
PADUA Score for VTE

Patient’s Score:
0
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. CML - - Non Pharmacotherapy : BMP evaluation,
Mr. AB / 48.y.o/Ward 27
Accelerated - High Calories high protein Sign of TLS
Subjective Phase Diet 2000 kcal/day
- Fatigue P.Ed:
- Diagnosed with CML Pharmacotherapy Educate Patient
- Routinely consumed - IVFD NS : Futrolit 3:1 and the family
Tasigna 2x400mg 2000cc/24hr that patient
- had been done - PO Nilotinib 2x400mg  condition was
leucopharesis 2 weeks ago postponed (high risk for progressively
worsening anemia) worsened
Objective
Abd : lien schuffner 6/8 Patient
compliance for
Laboratory medication
Hb 4.3
Leucocyte : 494,870
Diff. Count :
0.6/1.1/74.1/17.4/6.8%
Blood Smear Leucocytes: The
number is greatly increased,
cell blast (+)

BCR ABL 13/8/2019 :

Average ABL 1.28 106
Average BCR-ABL 3.69 x 105
BCR ABL/ABL 28.3%
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Hyperleucocyte - - Non Pharmacotherapy : UOP, CBC post
Mr. AB / 48.y.o/Ward 27
dt No 1 with - High Carbohydrate high Leucopharesis,
Subjective Tumor Lysis protein Diet 2000 Leucostasis
- Diagnosed with CML Syndrome (TLS) kcal/day sign,
- had been done - Oral intake 2-3L/day, Urine Ph, Sign
leucopharesis 2 weeks target UOP 100 cc/hours of TLS
ago
Pharmacotherapy P.Ed:
Objective - IVFD NS : Futrolit 3:1 Educate Patient
Abd : lien schuffner 6/8 2000cc/24hr and the family
- PO Nilotinib 2x400mg  about
Laboratory postponed (high risk for leucostasis sign
Hb 4.3 worsening anemia) and condition
Leucocyte : 494,870 - PO Allopurinol 1x300mg can be
Diff. Count : - PO Nabic 3x500 mg worsened over
0.6/1.1/74.1/17.4/6.8% time
Uric acid 9,2 mg/dL - Pro Leucopharesis
K: 6,03 / Ca: 8,8 / Pho: 4,0 - Dialysis considerations Patient
compliance for
Blood Smear Leucocytes: medication
The impression of the
number is greatly increased,
cell blast (+)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Anemia 3.1 related to Reticulocy Non Pharmacotherapy : RR, O2
Mr. AB / 48.y.o/Ward 27
Normochrom CML te - High Carbohydrate high hunger sign,
Subjective Normositer 3.2 Chronic protein Diet 2000 transfusion
- Fatigue, accompanied Inflammation kcal/day reaction,
with shortness of breath - O2 NC 2-4 lpm CBC post
- Diagnosed with CML transfusion
Pharmacotherapy
Objective - Postponed PO Nilotinib
RR : 24 tpm 2x400 mg (high risk for PEd :
SpO2 : 90% RA  98% on worsening anemia) Possibility
NC 4 lpm - Pro transfusion PRC 2 cause of
Anemic Conjunctiva (+) pack/day until Hb > anemia in
Extr: looked pale 10gr/dL patient of
CML
Laboratory
Hb : 4.3
MCV / MCH : 92.90/34.1
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
4. SOB + 4.1 CAP CXR, BGA Non Pharmacotherapy : Pmo :
Mr. AB / 48.y.o/Ward 27
Rhonki at lung 4.2 Leucemic Sputum - O2 NC 2-4 lpm S,VS, Sat O2,
Subjective basal D Lung culture - Oral intake 2-3L/day, RR, CXR
- Shortness of breath target UOP 100 cc/hours evaluation,
- Intermittent fever since BGA
3 days ago Pharmacotherapy evaluation
- Diagnosed with CML - IVFD NS : Futrolit 3:1
- had been done 2000cc/24hr
leucopharesis 2 weeks - IV Levofloxacin 1x750mg PEd :
ago Possibility
cause of
Objective shortness of
RR : 24tpm breath,
SpO2 : 90% RA  98% on planning
NC 4 lpm diagnose,
Rhonchi at basal Dextra and planning
theraphy
Laboratory
Leucocyte : 494.870
Diff. Count :
0.6/1.1/74.1/17.4/6.8%
 Problem Analysis

Clonal proliferation of hematopoietic

progenitor

CML Hyperleucositosis

Leukemic infiltration

Immunocomprimised condition Leukemic Lung

Bone marrow infiltration

Anemia CAP
 Risk Factors Analysis

Problem Theory Patient

CML The only risk factors for chronic myeloid Age 48

leukemia (CML) are: male
Radiation exposure: Being exposed 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 goes up with
age
Gender: This disease is slightly more
common in males than females, but it's
not known why

American Cancer society

Key Message Pathophysiology
 Key Message Pathophysiology
CML
(Chronic Myeloid Leukimia)

PATHOPHISIOLOGY
Translocation ABL in
chromosome 9th with
gene BCR in
chromosome 22 
BCR-ABL Protein
Bcr/Abl fusion proteins
can transform
hematopoietic
progenitor cells in vitro.
 Key Message Pathophysiology
Tumor Lysis
Syndrome
Key Message Diagnosis
Key Message Diagnosis
Key Message Diagnosis
 Management Analysis
Problem Theory Patient

CML The goal CML treatment is to achieve complete remission • PO Nilotinib

Including haematological remission, cytogenetic remission, and even 2x400 mg
biomolecular remission (postponed)
• PO Allupurinol
To achieve hematological remission by 1x300 mg
using myelosuppressive drugs : • PO Nabic 3x500
mg
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
Key Message Management
 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 Social

• Patient with CML must be educated for the planned

evaluation (BMP) and compliance of the drugs and
planning treatment
• Good emotional support from the family, health care
provider, and spiritual support must be given to the
patient
 Condition This Morning

GCS : 4-5-6
BP : 108/65 mmhg
HR : 81 bpm
RR : 20 tpm
SpO2: 98% RA