CLINICAL CONFERENCE

HEMATOLOGY ONCOLOGY DIVISION

(New Case)
April 10 , 2023
th

Nur Aisyah/ Presenter

Nita Anugerah Wati, Lory Iswanto, Siti Sophia/ Madya
Kharisma AH, Syahrurrahman, Kartika Setiawatt, Dina Fadhilah Monika,
Arwini Avissa/ Senior
 PATIENT IDENTITY
HO, 6 years 5 Mounths (Male)
MR Number 1016363
Date of Birth August 28th, 2016
Admission Date April 6th, 2023

MEDICAL DIAGNOSIS
Leukemia + Community Acquired Pneumonia
Thrombocytopenia + Profound Neutropenia+ Hypokalemia+
Nutritional marasmus
 HISTORY TAKING
Chief Complaint
Pale
History of Present Illness
6 years 5 Mounths old boy was reffered from Johannes Leimena Ambon hospital with
diagnosed of Acute Leukemia + thrombocytopenia+ Pneumonia.
There was pale noticed since 3 months before admitted to the hospital.
There was no fever, there was history of fever 2 days ago,not continuous , no seizure.
There was cough with Phlem, There was no shortness of breath, no blood.
No vomiting.
Urination: yellow normal
Defecation: yellow, normal.
 HISTORY TAKING
History of Past Illness
- There was history of pale notice since november 2022
- There was no history of gum bleeding, epistaxis petechie, melena and hematuria, family history
of malignancy, history living near the factory of rice fields.
- There was history of blood transfution, PRC 3 bags an TC 26 Unit in Johannes Leimene Ambon
Hospital
- There was no history of fever > 2 Weeks, contact with Tuberculossis sufferers, and weight loss
- There was history of chough >3 weeks
 HISTORY TAKING
History of Past Illness
- History of being diagnosed with tuberculosis since August 2022 and receiving OAT
therapy for 6 months, now the treatment has finished.
- History of being treated in Johannes Leimena Ambon Hospital for 10 days and got
treated by Ceftriaxon/intravenous, Paracetamol/intravenous, Farbivent/Inhalation
Packed red cell transfusion/intravenous, and Thrombocyte transfusion/intravenous.
 IMMUNIZATION HISTORY
Month Years
Vaccine Not 0 1 2 3 4 5 6 7 8 9 12 15 18 24 3 5 6 7 8
given
Hep B √ √ √ √

BCG √
DPT √ √ √ √

Hib √ √ √ √
OPV √ √ √ √
IPV √
Measles √
Rotavirus √
Influenza √
Japanese √
Encephalitis
PCV √
Varicella √
Hepatitis A √
Tifoid √

Vital Sign
General condition: Severe ill/severely
wasted/GCS 15 (E4M6V5)
Blood pressure : 100/60 mmHg
Heart Rate : 104 times/min
Temperature : 37°C
Respiration Rate : 26 times/min
SpO2 : 98%
Pain Scale : 0 FLACC
PHYSICAL EXAMINATION
Antropomethry
Body weight : 16.5 kg
Length : 117 cm
Head Circumference : 51 cm, normocephal
(Normal: 49-54 cm)
Weight for Age : under weight
Length for Age : normal stature
Weight for Height : Wasted
Head circumference : 51 cm
(Normal: 49 - 54 cm)
Normocephal
 Weight for age:
16.5/22 x 100% = 75%
Weight for Height : wasted
Under weight
Under -3 SD

Length for age:

117/118 x 100% = 99%
Normal stature

Weight for length:

16.5/22 x 100% = 75%
Wasted
 PHYSICAL EXAMINATION
There was no pale. No icterus
No stomatitis
Pulmo
There was xylophone ribs
Vesicular breath sounds
Pharynx not hyperemic
There was ronchi. No wheezing.
Tonsil T1-T1 Not hyperemic

There was lymphadenopathy Cardiovascular

- Retroauriciular dectra 1 pc, 1x1 cm I / II heart sound, Regular rhythm no murmur
- Retroauriciular sinistra 2 pc, 1x1 cm
- Submandibular dextra 1 pc, 2x1 cm Abdomen
- Submandibular sinistra 1 pcs, 3x2 cm
Flat, no distended. Peristaltic sound : normal
Palpable Gland:
Liver was palpable 3 cm under arcus costae.
- Ingunal dextra 4pcs, 1x1cm
Lien was palpable Schuffner I.
- Inguinal sinistra 4pcs, 1x1cm
 PHYSICAL EXAMINATION
Genitalia : There was 2 testis in the scrotum, 1,5 x 1,5 x 1 cm

Spontaneus bleeding manifestation : Petechie in Palatum and

Gluteus

Bleeding Time : 8 minutes 30 seconds

 PHYSICAL EXAMINATION
Tuberculosis Score
Contact 0
Mantoux 0 (not yet)
Nutrition 2
Fever 0
Cough 0
Lymphadenopathy 1
Swelling of the joints 0
Thorax Photos 1
Total 4
 LABORATORY FINDING
Laborat 26/3/2023 29/3/2023 02/4/2023 06/4/2023
Normal Value
ory (Ambon) (Ambon) (Ambon) (Wahidin)

RET - - - 0.23

Hb 5 6,7 12.4 11.2 12.0 – 16.0 gr/dL

WBC 36.160 19.940 2.700 2.600 4.0 – 10.0/μL

ANC 108.48 59.82 186.3 49.4
150.000 –
PLT 11.000 14.000 9.000 9.000
400.000/mm3
MCV 80 76 80 80 80 -100 μm3
MCH 28 27 28 28 27 - 32 Pg

NEUT 0,3 0.3 6.9 1.9 52 – 75 103/μL

LYMPH 87.2 77.4 93.1 95.8 20 – 40 103/μL

MONO 12.2 22.2 0 2.3 2 – 8 103/μL

Laboratory 6/4/2023 (Wahidin)

Ureum 26
Creatinine 0.23
AST 15
ALT 28

Albumin 4.9

Natrium 137
Kalium 3.2
Clorida 107
Peripheral Blood Smear (27/2/2023 Johannes Leimena Ambon Hospital)
• Erythrocytes : normocytic normochrome, anisocypoikilocytosis, ovalocyte (+),
inclusion bodies (-), normoblast (-), pencil cell and Spherocyte (+)
• Leukocytes : Sufficient quantity, dominated pleomorphic cells suspected of blast,
Lymphocyte>PMN
• Platelets: decreased quantity, normal morphology
• Result: suspected of acute lymphoblastic leukemia (ALL)
• Suggestion: Bone Marrow Puncture
RADIOLOGY FINDING
Thorax Photo RSWS (26/3/2023)
Impression :
- Normal cor
- Coarse bronchovascular pulmo in the right
parahilar
- Both phreniccostal sinuses are sharp
Conclusion: Bronchitis
 ASSESMENT

 Anemia
 Thrombocytopenia
 Lymphpositosis
 Leucopenia
 Profound neuthropenia
 Pneumonia
 Organomegaly
 Hypokalemia
 Wasted
 WORKING DIAGNOSIS
 Leukemia
 Community Acquired Pneumonia
 Nutritional Marasmus
 Treatment
- KaEn 3 B/ Intravenous (Hypokalemia was corrected with maintenance)
- 5)ceftriaxon /intravenous
- 1)gentamicin /intravenous
- Paracetamol 400mg/ 8 hours/ intravenous (if temperature >38.5 C or Pain scale >3FLACC)
- Ambroxol/oral
- Thrombocyte concentrate transfusion/ 12 hours/ intravenous
- Observation for spontaneous bleeding manifestation
- Observation for signs of infection
 TREATMENT
- Mangement of Malnutrition (WHO), Stabilization phase :
- Vitamin A/oral
- Vitamin b complex/oral
- Vitamin c/oral
- Folic acid/oral
 PLANNING
- Tracking of leukemia: Bone Marrow Puncture and Immunophenotyping
- Peripheral Blood Smear in Wahidin Hospital
- Urinalysis routine
- Consult to respirology division
- Consult to nutrition and metabolic disease division
THANK YOU