HEMATOLOGI CASE REPORT

A 2 years , 10 months Boys with ALL-SR Pro Chemoterapy weeks 12th

Asked to fulfill the duty of the Registrar

in the Pediatric departement

Arranged by:

Reza Sebastian Prakasa 22010116210028

Penguji :

dr. Yetty Movieta N, Sp.A(K)

FAKULTAS KEDOKTERAN UNIVERSITAS DIPONEGORO

SEMARANG
2017
A. Patient Identity
Nama : An. AAD
Age : 2 years 10 months
Date of birth : 01 January 2015
Gender : Boys
Adress : Demak
Religion : Islam
No. CM : C651068
Bangsal : Anak lantai 1
Date of entry : 22 September 2017

B. Basic Data
Anamnesis
Alloanamnesis with patient mother in C1L1 RSUP DR kariadi

a. Main complaint : pro chemoterapy

b. History of illness
+ 10 month before entering hospital , patients often have fever up to 390C, seizures,
red spots appear and then patient was treated at Pelita Anugerah Hospital.
Then,patients are examined blood but the result is normal. + 6 months before entering
hospital, patients suddenly cough, fever, runny nose and seizure, then performed a
laboratory examination and the results are hemoglobin 7 , trombosit 20.000, then
performed a blood transfusion 3 yellow kolf, and 1 red kolf, patients then experience
improvement and can go home. 5 months before entering the Hospital patien
suddenly cough and high fever, patient brought to Roemani Hospital and conducted
laboratory check with result of platelet 15.000. The patient was diagnosed with ITP
and was recommended to be referred to the Kariadi Hospital but patient refused. The
patient's mother then took the patient to the hospital with the results of the lab of
peripheral blood and was said to be suffering from typhoid fever. Then,Patients were
given antibiotics and paracetamol, the patient had improved but 5 days later the
patient's condition decreased and then taken to Ketileng Hospital. Laboratory result
hb : 3,8 , platelet 3000, ptekie (+), bleeding gums (-),epistaksis(-), bone pain (-).then
performed transfusion of yellow blood 4 kolf, red blood 2 kolf, After being evaluated,
 platelets increased slightly and decreased after 3 days, the patient was later said to
have blood disorders and should be referred to the Kariadi Hospital. In Kariadi
Hospital, the patient performed BMP and diagnosed ALL-SR,
patients undergoing chemotherapy treatment on a regular basis until now. Currently
the patient undergoes the 12th chemotherapy, side effect chemoterapi hair loss (-),
nausea(+), vomiting(-), decreased appetite(-), cough(-), fever(-), runny nose(-),
weight loss(-),
b.Past medical history
-History of illness like this before (-)
- History of previous malignancies (-)
-Allergy history (-)
c. Family medical History
- Family history with malignant disease (-)
- Family history with similar complaints (-)
d. Socio economic History
The father of a worker and mother does not work, Bear 2 children who are not
independent yet,Medical expenses using BPJS Non PBI
The socioeconomic impression is lacking

C. SPECIFIC DATA
Prenatal, natal, dan postnatal History
Prenatal History : mothers aged 26 years during pregnancy, routine check of
pregnancy in midwife (> 4 times during pregnancy), taking
regular Fe supplement, TT (+) immunization, illness during
pregnancy (-), radiation exposure (-), trauma (-), consumption
drugs other than doctors / midwives (-), consumption of herbs
(-), hypertension and diabetes during pregnancy (-)
Natal History : born baby boy from mother G2P1A0, gestational age aterm,
born Sectio caesaria in Hospital, direct cry, active (+), pale (-
), cyanosis (-), BBL : 3900 gram, PB : 51cm
Post Natal History : routine child is checked at posyandu for weighing and
immunization. Yellow (-), seizure (-)
Imunization History :
Hepatitis B : 4 times (0,2,3,4 Month)
 Polio : 4 times (0,2,3,4 Month)
BCG : 1 times (1 Month, scar (-))
DPT : 3 times (2,3,4 Month)
Hib : 3 times (2,3,4 Month)
Campak : 1 times (9 Month)
Impression: complete basic immunization according to age. Booster (-)

Growth History
BBL : 3900gr
PB L : 51cm
Weight : 14 kg
Height : 95 cm
WAZ : 0,13
HAZ : 0,12
WHZ : 0,10
Kesan: good nutrition, normal stature mesosefal
Developmental history
Stomach (tengkurap) : 3 months of age
Sit : 6 months of age
Stand up straight : 8 months of age
Speaking : 12 months of age
Walking on hold : 9 months of age
Walking : 10 months old
Impression: normal development according to age

D. Physical Examination
Awarness : Compos mentis, good
Vital Sign
Heart rate : 120 x/minutes,reguler
RR : 30 x/minutes
Temperature : 37C
Head : mesosefal
Hair : Hair loss (-)
Eye :Conjungtiva anemis (-/-),Sclera Icterik (-/-)
Nose : epistaksis (-),discharge (-)
Mouth: pale lips (-), bloody lips (-), bleeding gums (-), cyanosis (-)

Neck: enlargement nnll (-)

Throat: tonsils T1 / T1, pharyngeal hyperemic (-)
Leather: ptechiae (-)
Axilla : enlargement nnll (-)

Chest :
Heart :
I : IC was not seen
P : IC was palpable at 5th ICS, 2 cm medial to Mid Clavicle Line
P : Configuration normal
A : Pure heart sound, no murmur
Lung :
I : Static : Right hemithorax = Left hemithorax
Dynamic : Right hemithorax = Left hemithorax
P : Tactile fremitus was equal on both side
P : Sonor on all area
A : Basic sound was vesicular, no additional sound
Gastrointestinal System
Inspection: flat, plush
Auscultation: normal bowel sound (+)
Percussion: tympanic, normal sidebound (+), deafness (-)
Palpation: supel, liver and lien are difficult to assessInguinal : enlargment nnll (-)
Musculosceletal system
Exstremitas Superior Inferior
- Cyanosis -/- -/-
- Coldacral -/- -/-
- Capillary refill time <2 <2
- Pale -/- -/-
- oedem -/- -/-
- ptekie -/- -/-
E. ANTROPOMETRI EXAMINATION
Boy , age 2 tahun 9 bulan
Weight : 14 kg WAZ : 0,13
Height : 95 cm HAZ : 0,12 SD
WHZ : 0,10 SD

Explanation

Kesan : good nutritional, normal statue,mesosefa;

F. LABORATORY STUDY
1. Hematologi
Hematologi 22/9/2017 Satuan Normal value
value
Hemoglobin 13,1 gr% 9,50 12,50
Hematokrit 39,3 % 32,0 44,0
Eritrosit 4,68 juta/mmk 3,90 5,50
MCH 26 Pg 24,00 34,00
MCV fL 83,00
85
110,00
MCHC 32,9 g/dl 29,00 36,00
Leukosit 6,6 ribu/mmk 6,00 17,50
Trombosit 213 ribu/mmk 150,0 400,0
Kimia klinik 22/9/17 Satuan Normal
Value
Ureum 19 mg/dL 15 39
Creatinin 0,6 mg/dL 0,60 1,30
Calcium 2,41 mmol/L 2.12 2.52
Elektrolit 22/9/17 Satuan Normal
Value
Natrium 141 mmol/L 136 145
Kalium 4,9 mmol/L 3.5 5.1
Chlorida 108 mmol/L 98 107
 GDS 83 mg%

G. PROBLEM LIST
Tabel 4. Problem List

No. Problem Aktif Date No. Problem aktif

1. ALL-SR Pro Chemoterapy 24 Sept
th 2017
weeks 12

H. DIAGNOSIS KERJA
th
ALL-SR Pro Chemoterapy weeks 12

I. Initial Plan
th
ALL-SR Pro Chemoterapy weeks 12
IpDx : S: -
O: -
IpRx :
Infus D5 NS 480/20/5 tpm
Mtx Dt 12 mg
Mtx HD 600mg IV
Vincristin 90 mg IV
Ondansetron 4 mg IV

IpMx : DR, Ur/Cr/eelectrolit,Ca, GDS

IpEx : Education to the patient's family about chemotherapy procedures

and side effects

2. Good Nutritional, Normal stature, mesosefal

 IpDx : S: -
O: -

IpRx :

Fluid Calorie Protein

Need 1200 1390 17,09

Diet are given

Diet lunak 200 678 28,84

D5 NS 480 81,6

Pediasure 300 300 8,7

Total 980 1059 27,04

AKG 81,6% 76,2% 219%

IpMx : Increased weight, akseptabilitas diet

IpEx : explained to the mother that the child to eat food and milk given
from the hospital

J. PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad malam
Quo ad sanationam : dubia ad malam