CLINICAL CONFERENCE

Hemato-oncology Division
(Death Case)
January 19th, 2021

Hardiyanti, Nurul Hikmah/ Presenter

Clara Parannuan / Liesa Ferawaty / Madya Division
Andi Utari Dwi Rahavu / Andi Avu Hafsari M / Ivana Yunita / Musdalipa/
Astri Amelia Gosal / Senior Division
 PATIENT IDENTITY
CN 12 Years 4 Month (male)
MR Number 960195
Date of Birth 15-11-2008
Admission Date 3-1-2022

MEDICAL DIAGNOSIS
• HYPOVOLEMIC SYOK • IRON DEFICIENCY ANEMIA DIFFERENTIAL DIAGNOSIS OF
• ABDOMINAL TUMOR ET CAUSA NEUROBLASTOMA ANEMIA OF CHRONIC DISEASE
DD/NEPHROBLASTOMA • HYPOALBUMINEMIA
• OMENTUM TUMOR • TINEA VERSICOLOR
• SUSPECT PERITONITIS TUBERKULOSA
 HISTORY TAKING
Chief Complaint
Enlarged stomach since 1 month
History of Present Illness
The patient was referred from Bahagia’s Hospital with diagnosis Abdominal tumor.
There was a lump in the stomach noticed since 1 month ago, the lump was noticed getting bigger.
No fever, no seizure
No cough, no shortness of breath
No vomiting
Poor Appetite
Urinating and defecation were normal.
HISTORY OF ILNESS

No history of frequent fever.

No history of weight loss .
No history of joint pain.
No history of blood transfusion.
No family history of malignancy.
No history of contact with a patient with a long cough.
History of being treated at Bahagia Hospital for 3 days with a diagnosis of
abdominal tumor and receiving ringer lactat infusion and paracetamol and then
reffered to Wahidin’s hospital.
History of being treated at Wahidin hospital for 14 days. On 13th day the patient
was performed laparotomy exploration and referred to ICU.
TB SCORE
CONTACT WITH TUBERCULOSIS PATIENT (0)
NUTRITIONAL STATUS (2)
MANTOUX TEST (YET)
OLD FEVER (0)
LONG COUGH (0)
LYMPADENOPATHY (0)
JOINT SWELLING (0)
CHEST X-RAY (1)

SCORE : 3

Vital Sign
General condition: moderate illness /
good nourshied/GCS 15 (E4M6V5)
Blood Pressure : 100/70 mmHg
Heart Rate : 110 times/min
Temperature : 37 °C
Respiration Rate : 26 times/min
SpO2 : 99%
Pain Scale : 0 NRS
PHYSICAL EXAMINATION
Antropomethry
Body weight : 44 kg
Length : 152 cm
Head Circumference : 52 cm, Normochepal (Normal:49 cm – 55 cm)
Weight for height : 44/45 x 100% = 97,7% (sev good nourished)
Weight for Age : 44/ 48 x 100% = 91,6 (normal weight)
Height for Age : 154 / 160 x 100% = 96,25% (normal stature)
Head Circumference : 52 cm,
Normochepal
(Normal:49 cm – 55 cm)
Weight for height : 44/45 x 100% = 97,7% (sev
good nourished)
Weight for Age : 44/ 48 x 100% = 91,6 (normal
weight)
Height for Age : 154 / 160 x 100% = 96,25%
(normal stature)
 PHYSICAL EXAMINATION
History of Vaccine
Frequency
Vaccine Not given 1 2 3 4

BCG V
Hep B v
DPT V

Hib V
Polio v
MMR V
Rotavirus V
Influenza V
Japanese Encephalitis V
PCV V
Varicella V
Hepatitis A V
Tifoid V
No pallor, no icterus
PHYSICAL EXAMINATION
Heart: regular I/II heart sound.
no stomatitis
no lymphadenopathy No murmur

Pulmo Abdomen: peristaltic normal.

vesicular breath sounds, palpable mass in the dextra hypochondrium, size 10x7,5x2 cm, no

No rales and wheezing
Score TB:
CONTACT WITH TUBERCULOSIS PATIENT (0)
NUTRITIONAL STATUS (0)
passing through the midline shift, solid consistency, no tenderness,
regular surface, no visible veins prominent color and temperature tactile
the same as surrounding area.
Extremities: No pitting edema, warm akrall

MANTOUX TEST (YET) Genitalia: palpable 2 testes in the scrotum, size 2.5 x 1,5x 1,5 cm.
OLD FEVER (0)
Spontaneous bleeding manifestations: none
LONG COUGH (0)
LYMPADENOPATHY (0) Other:
JOINT SWELLING (0)
Multiple macula hypopigmentation at regio collie and thoracal.
CHEST X-RAY (o)
SCORE : 0
 Laboratory
January 4th
2022
(Wahidin)
January 7th
2022
(Wahidin)
January 10th
2022
(Wahidin)
January 12th
2022
(Wahidin)
January 14Th
2022
(Wahidin)
Normal Value LABORATORY
RET
Hb
WBC
-
10,5
14.700
-
10,5
22.800
10,1
11.000
1,53
11,0
17.800
-
10,4
13.700
0.00 – 0.10 10^3/ul
12.0 – 16.0 gr/dL
4.0 – 10.0/μL
FINDING
PLT 592.000 440.000 192.000 286.000 440.000 150.000 – 400.000/mm3

MCV 74 76 76 73 72 80 -100 μm3

MCH 23 23 24 23 23 27 - 32 Pg
NEUT 63,9 79,6 64,5 69,7 58,8 52 – 75 103/μL

LYMPH 18,1 9,5 23,6 17,3 21,1 20 – 40 103/μL

MONO 14,7 8,6 8,3 10,1 17,3 2 – 8 103/μL

GDS 92 - 87 - - 140
NATRIUM 135 - 132 132 135 136 – 145
KALIUM 3,8 - 4,1 3,7 3,4 3.5 - 5.1
CLORIDA 96 - 93 94 102 97 - 111

SGOT / SGPT - - 36/5 - - < 38 / <48

ALBUMIN 3,4 - 3,5 3,3 2,9 3.5 – 5.0

UREUM 7 - 12 - - 10 – 50

CREATININ 0,52 - 0,5 - - L (<1.3) P (<1.1)

PT - - - 10,1 - 10-14
APTT - - - 27,2 - 20-30

INR - - - 1,01 - -

FERITINE 212,28 - - - - 13.0-400.0 ng/ml

LDH 3.247 - - - - 210 - 425

PERIPHERAL BLOOD SMEAR (4/1/2022)
• Erythrocytes: Micrositic hypocrom, anisopoikilositosis, ovalocytes (+), pencil cell (+), anulosit (+),

inclusion bodies (-), Normoblasts (-)

• Leukocytes: increased amount, PMN > lymphocytes, toxic granulation (+),vacoolisation(+), blast cell

(-)

• Platelets: increased amount, normal morphology.

• Impression: Micrositic hypocrom anemia suspected causa fe deficiency accompanied by leukocytes

with signs of infection, Trombocytosis Reactive.

Sputum BTA 3x in Wahidin’s Hospital 17/1/2022:
Type of specimen : Sputum
BTA 1 : Negatif
BTA 1 : No sampel
BTA 3 :-
Chest X-ray in Wahidin’s Hospital 6-1-2022)

Impression:

• Fibrosis Pulmo Bilateral

• Cor normal
USG Abdominal 28/12/2021:
Impression: dominant hypoechoic retroperitoneal mass at the level of the right kidney extraluminous
impression suspected neuroblastoma/nephroblastoma/ other retroperitoneal mass
MSCT - ABDOMEN SCAN WITH CONTRAST IN WAHIDIN 5/1/2022:
• SUSPECT PERITONITIS TB WITH OMENTAL CAKE MASS
DEXTRA
• LOCULATED ASCITES IN PELVIS
• PLEURAL EFFUSION
 ASSESSMENT
• HYPOVELEMIK SYOK
• SEPSIS
• ABDOMINAL TUMOR ET CAUSA
NEUROBLASTOMA DD/NEPHROBLASTOMA
• OMENTUM TUMOR
• SUSPECT PERITONITIS TUBERKULOSA
• PLEURAL EFFUSION
• IRON DEFICIENCY ANEMIA DIFFERENTIAL
DIAGNOSIS OF ANEMIA OF CHRONIC
DISEASE
• HYPOALBUMINEMIA
• TINEA VERSICOLOR
 TREATMENT
• INFUSION DEXTROSE 5% • ALBUFORCE/ ORAL

• TRACKING INTRAABDOMEN TUMOR: • COLLABORATION WITH RESPIROLOGY

• COLLABORATION WITH PEDIATRIC DIVISION:
SURGERY: • TRACKING TB
• LAPARATOMY EXPLORATION + BIOPSY • MANTOUX TEST
TUMOR (14/1/2022)
• COLLABORATION WITH
• CEFTAZIDIME / INTRAVENOUS DERMATOVERENOLOGY DEPARTMENT:

• PARACETAMOL/ INTRAVENOUS • KETOKONAZOLE/ ORAL

• MICONAZOLE ZALF
14/1/2021 (16.00)
Subjective
HISTORY TAKING
Assessment
• ABDOMINAL TUMOR ET CAUSA NEUROBLASTOMA
DD/NEPHROBLASTOMA
There was enlarge stomach • OMENTUM TUMOR
No fever, no seizure • SUSPECT PERITONITIS TUBERKULOSA
No cough, no shorthness of breath
• PLEURAL EFFUSION
No vomiting
• IRON DEFICIENCY ANEMIA DIFFERENTIAL DIAGNOSIS OF ANEMIA
Urination and defecation were normal OF CHRONIC DISEASE
Objective • HYPOALBUMINEMIA
General condition: weak • TINEA VERSICOLOR
Blood Pressure : 90/60 mmhg
Heart rate 94 time / palpation Therapy
Respiration rate : 22 time / minute
• INFUSION DEXTROSE 5%
SPO2 : 99 %
temperature : 37 C
Capilarry refill time <3 second • TRACKING INTRAABDOMEN TUMOR:
warm acral
• COLLABORATION WITH PEDIATRIC SURGERY:

Abdomen: peristaltic normal. • LAPARATOMY EXPLORATION + BIOPSY TUMOR

palpable mass in the dextra hypochondrium, size 10x7,5x2 cm, no
• CEFTAZIDIME / INTRAVENOUS
passing through the midline shift, solid consistency, no tenderness,
regular surface, no visible veins prominent color and temperature • PARACETAMOL/ INTRAVENOUS
tactile the same as surrounding area
• ALBUFORCE/ ORAL

• COLLABORATION WITH RESPIROLOGY DIVISION

14/1/2021 (18.50)
Subjective
The patient on ventilator mechanic
Objective
General condition: weak
GCS: on sedation
Heart rate : 98 time / palpation
Respiration rate : 28 time / minute
SPO2 : 100 % via ventilator mechanic
temperature : 37,0 C
Capilarry refill time <3 second
Therapy
warm acral Oxygenation via Ventilator mechanic
Residu : 50 cc greenish colour
Drain: 100 cc
Ceftazidim/ intravenous
Ranitidin/ intarvena
Assessment Tranexamat acid/ intravenous
POST OP LAPARATOMY EXPLORATION + TUMOR BIOPSY
Metronidazol/ intravenous
ABDOMINAL TUMOR ET CAUSA NEUROBLASTOMA DD/NEPHROBLASTOMA Metamizol/ intravenous
OMENTUM TUMOR
SUSPECT PERITONITIS TUBERKULOSA
PLEURAL EFFUSION
IRON DEFICIENCY ANEMIA DIFFERENTIAL DIAGNOSIS OF ANEMIA OF
CHRONIC DISEASE
HYPOALBUMINEMIA
TINEA VERSICOLOR
14/1/2021 (19.00)
Subjective
There was apneu and bradycardi
Objective
General condition: weak/GCS on sedation
Heart rate 45 time / palpation
Respiration rate : -
SPO2 : 70 % via jackson reese
temperature : 37,0 C
Capilarry refill time >3 second
Cold acral
Drain: 200 cc
Assessment
Therapy
• HYPOVOLEMIC SYOK Oxygenation via Jackson reese
• ABDOMINAL TUMOR ET CAUSA NEUROBLASTOMA Cardiopulmonary resuscitation (30:2)
DD/NEPHROBLASTOMA Epinephrine 1:10.000
• OMENTUM TUMOR
• SUSPECT PERITONITIS TUBERKULOSA
• PLEURAL EFFUSION
• IRON DEFICIENCY ANEMIA DIFFERENTIAL DIAGNOSIS OF ANEMIA OF
CHRONIC DISEASE
• HYPOALBUMINEMIA
• TINEA VERSICOLOR
 14/1/2022 (20.35)
Subjective
Patient was not breathing, no movement
Objective
General condition: poor
Heart rate no palpable
Respiration rate : no breath
Total pupil midriasis
Capillary refile time more than 3 seconds
Corneal reflex negative

And Patient Pass away

 CAUSE OF
DEATH
HYPOVOLEMIC SYOK
WORSENING BY:
• ABDOMINAL TUMOR ET CAUSA NEUROBLASTOMA DD/NEPHROBLASTOMA
• OMENTUM TUMOR
• SUSPECT PERITONITIS TUBERKULOSA
• PLEURAL EFFUSION
• IRON DEFICIENCY ANEMIA DIFFERENTIAL DIAGNOSIS OF ANEMIA OF CHRONIC DISEASE
THANK YOU