TIMELINE

Jan 27th 2018 Jan 28th 2018 Jan 29th 2018 Feb 4th 2018 Feb 8th 2018

Examination Observation Final Reporting

Patient was started Observation
admitted to
Kandou
Hospital

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 PATIENT’S RECORD

I. IDENTITY
Patient Identity
Patient Name : SP
Sex : Male
Age : 8 years 7 months old
Date of birth : 21 June 2009
Place of birth : Home
Nationality : Indonesia
Ethnic : Minahasanese
Religion : Christian
Date of Examination : 28 January 2018
Registration Number : 41.15.XX

Parental Identity
FATHER MOTHER
Name : NM MP
Age : 53 years old 49 years old
Occupation : Farmer Housewife
Last Education : Junior High School Junior High School

II. HISTORY
(Based on Allohistory taking from the parents and medical record, 28
January 2018 in Estella)
Chief Complaint : patient admitted to hospital to continue the
chemotherapy
Additional Complaint :-

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Present Illness
Patient admitted to Kandou hospital at January 27 th 2018 at 16.00
WITA with chief complaint wanted to continue the chemotherapy second
cycle on January 30th 2018 Patient has been diagnosed with acute
myeloblastic leukemia from December 20th 2017.
During this time, patient didn’t have fever or common cold. He had
a good appetite and the parent said that patient usually have meal 3 times
a day.

Past Illness
Patient was first diagnosed with acute myeloblastic leukemia on
December 2017. A month before diagnosed, the patient had fluctuated
fever. Patient also looked pale and fatique. Patient was taken to the
Noongan hospital and was referred to Kandou hospital for further
examination, after 4 days care. Patient has been diagnosed with acute
myeloblastic leukemia at the beginning of December 2017 and treated
with AML chemoterapy protocol since December 20 th 2017.

Family History
Only patient had this complain in his family.

Family tree

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Family Member
No Name Relationship Sex Age Details
with patient
1. NM Father M 49 years Healthy
2. MP Mother F 53 years Healthy
3. SM Sibling F 32 years Healthy
4. AM Sibling F 27 years Healthy
5. BM Sibling M 23 years Healthy
6. SM Patient M 8 years 7 months Patient

PERSONAL AND SOCIAL HISTORY

HISTORY OF ANTENATAL CARE

Patient’s mother had antenatal care 4 times at the Public Health Care. The
mother had Tetanus Toxoid (TT) immunization 2 times and she was
healthy during pregnancy.

HISTORY OF LABOR
Patient was born spontaneously, aterm, cried spontaneously, birth weight
was 3000 gram, birth length was 49 cm, at home and was assisted by
midwife.

HISTORY OF POSTNATAL
Patient had never experienced any cyanotic or yellowish skin color. He
breastfed and was routinely taken to health care facility for vaccination
until nine months old.

HISTORY OF FEEDING
Patient got exclusive breastfeeding until 6 months old and continued until
12 months. Milk porridge was given at 6 months old then changed to
strained porridge on 8 months old. Soft porridge was given on 10 months

4
old. Since patient 12 months old until now, patient eats 3 times a day.
Patient usually eat fish, chicken, egg, tofu with vegetables and fruits.

DEVELOPMENTAL MILESTONES

GROWTH
Growth and development examination was routinely carried out until the
age of 9 months to the public health care and at that time, the growth of
the patient was normal.

DEVELOPMENTAL
Patient could prone in 4 months old, sit in 6 month olds, and stand up in 9
months old and walked in 15 months old. In 3 years, patient could follow
movement, and talk a sentence. In 5 years old, patient could talk clearly.

HISTORY OF IMMUNIZATIONS
Patient got BCG immunization in right arm, Polio 4 (four) times, DPT 3
(three) times, Hepatitis B 4 (four) times, Hib 3 (three) times and Measles 1
(one) time.

HISTORY OF CHILD BASIC NEEDS

Physic-biomedic
The patient received adequate food needs as his age. Patient eat three
times a day, eat 1 full plate each day, with rice, fish, dishes, and fruits.
Patient received wearable clothes, family house, good self hygiene,
adequate environmental sanitation, exercise and enough recreation.

Emotional Needs
Patient got care from both parents and all family members. All family
members support for patient medical care and recovery.

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Mental Stimulation
Patient loved to play with friends of his age. Now patient easily socialize
with his friends.

SOCIO-ECONOMIC AND ENVIRONMENT CONDITION

SOCIO-ECONOMIC
Patient’s father works as a farmer and his mother as housewife. The
Medical cost covered by National Health Insurance.

ENVIRONMENT
The patient lives with both of his parent and siblings, house with tin roof,
concrete wall, tile floor. The house consist of three bedrooms, lived by 5
person, 4 adults and 1 kid. The bathroom is inside the house, the source
of electricity from the government electric company. Handling of waste
disposal by removal. The environmental where the patient lived is placed
in countryside which isn’t densely populated. Patient usually contaminated
with pestisides when he visited her father at farm.

PATIENT RESUME BEFORE INDUCTED AS A CASE

(November 23th,2017 –January 27th,2018)
Patient referred from Noongan Hospital with diagnosis acute
bacterial infection and thrombocytopenia. Patient is treated in Noongan
Hospital with chief complaints fluctuated fever since 1 month before
admission. Patient also looked pale and fatique since 2 weeks before
admission. There wasn’t found spontaneous bleeding like gum bleeding,
nausea or vomiting on patient. During the hospitalization in Noongan
Hospital, patient got ceftriaxone injection. After 4 days hospitalized, patient
referred to Kandou Hospital for further examination.
Patient referred to Kandou Hospital on November 23th 2017. From
the physical examination was obtained that body weight 23 kg and height

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123 cm, with good nutritional status (CDC 2000). Patient appearance was
sick, compos mentis (GCS E4V5M6). Vital sign: Blood pressure 100/70
mmHg,heart rate 120 x/m, respiration rate 24 x/minute and temperature
38,00C. In head examination, there was an anemic conjunctiva and no
icteric sclera. In ophthalmology examination pupil rounded isochor,
diameter 3 mm and normal light reflects. In ENT examination, Tonsil T1-
T1 non hiperemis, faring non hiperemis. There was not hypertrophy
gingival; There was not palpable enlargement of the lymph nodes on the
neck region. Breathing sound bronchovesicular, there were no rhonchi and
wheezing. Heart sound I-II normal, there were no murmur. Abdomen was
flat, symmetrical chest wall movement, flaccid on palpation, liver was
palpable 1 cm sub arcus costa, lien was unpalpable. On the extremities,
CRT less than 2 seconds, warm, and no cyanosis. On skin there wasn’t
petechiae or echimosis.
Laboratory results on November 23th, 2017 Hb 10,2 g/dL, Ht 28,9
%, leukocyte 54.700/ mm3, thrombocyte 58.000 /mm3, ureum 20 mg/dl and
creatinine 0,5 mg/dl, SGOT 29 UL, SGPT 19 U/L, Sodium 135 meq/L,
Potassium 4,08 meq/L, Chlorine 96,5 meq/L.
From the blood smear examination on November 23th, 2018 was
found Eritrosit: anemia normocytic normochrom, eritrosit idichromasia (-),
pencil cell (-), ovalocyte (-), target cell (-), acanthocyte (-), stomatocyte (-),
tear drops cell (-), burr cell (-), fragmented (-), agglutination (-), roulaeux
formation (-), normoblast (+), malaria (-). Leukocyte: total increase,
dominan myeloid, vacuolitation (-), hyposegmentation (-), toxic granulation
(-), stab (-), aurer rod (-), blue plasma lymphosit (-), blast (+) 72%.
Eosinophil: 2%, basophil: 0%, segment neutrophil: 7%, rod neutrophil: 3%,
lymphosit: 11%, monosit: 5%. Thrombocyte: decreased total, giant
thrombocyte (-), thrombocyte aggregigation (-), megakarioblast (-).
Resume: anemia normocytic normochrom, normoblast (-), leukostasis,
myeloid, blast (+), thrombocytopenia, compatible with suspect acute
myeloid leukemi. On November 28th, 2018 was done bone marrow

7
puncture (BMP) examination to the patient. During waiting the BMP result,
the patient consulted to the cardiology division for echocardiography,
otolaryngology division and dentistry/oral surgery division for preparing the
chemoteraphy and there was no contraindication for chemotherapy from
their division. Radiological examination indicated normal lungs and heart.
EKG indicated sinus rhythmic.
From the BMP examination, was found thrombopoiesis:
megakariosite total increased, abnormal form (-), immature form
(-),thrombocyte production decreased. Diff count, myeloid: blast 63%,
progranulocyte (-), myelosyte 3,5, rod 1%, segment 9,5%, basophil 0%,
eosinophyl 0%; erythroid: rubriblast 0%, prorubricyte 0%, rubricyte 3%,
metarubricyte 2%; lymphosyt 11%, monocyte 5%, plasmocyte 0%,
hystiocyte 0%, mitosis cell (-), megaloblast (-). Resume: anemia normositic
normochrom, eritropoiesis activation, granulopoiesis, and thrombopoiesis
is suppressed, many blast cell morphology is like myeloblast, compatible
with AML M2. From the leukemia phenothyping was found gating in blast
cell looked in CD33, CD34, CD117, HLA-DR, CD13, CD7, CD10,
compatible with myeloid lineage with aberrant exp CD7 and CD10
Patient on December 14th, 2018, admitted again to hospital to start
the chemotherapy. Patient had laboratorium control examination and was
found Hb: 8,0 gr/dL, Ht: 22,3%, Lekosit: 89.500/mm3, Trombosit:
30.000/mm3, SGOT: 19U/L, SGPT: 15 U/L, ureum: 15 mg/dL, creatinin
0,5 mg/dL, Sodium: 131 mEq/L,Potassium : 2,75 mEq/L, Chlorine: 92,0
mEq/L.
On December 20th 2017 patient started to get chemotheraphy 1 st
cycle and got Metotrexate intratechal, doxorubicin and cytarabine for 5
days, with time and dose compatible with the protocol. From the
cerebrospinal liquor examination, BTA (-), wasn’t found bacteria gram (+)
or (-)

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 Examination 25/01/2018
Hb (g/dl) 9,9
Ht (%) 28,9
Leuco (/L) 2.300
Trombo (/L) 25.000
Diff.count (%) 1/0/1/50/39/9
ANC 1173
ALT (U/L) 46
AST (U/L) 49
Ureum (mg/dl) 29
Creatinin (mg/dl) 0,3
Clorida (mEq/L) 93
Kalium (mEq/L) 3,62
Natrium (mEq/L) 131
Calcium (mg/dl) 8,92
CRP (mg/L) -

III. PHYSICAL EXAMINATION

General Condition : Sick appearance
Consciousness : Compos mentis (GCS E4V5M6)
Weight = 22,5 kg
Height = 120 cm
Nutritional Status (CDC Curve 2000 2 to 20 years boys, Stature-for-age
and Weight-for-age percentiles)
Weight/Age : 22,5 / 27,5 x 100% = 81 % (Normal weight)
Stature/Age : 120 / 131 x 100% = 91,6 % (Normal Height)
Weight/Stature : 22,5 / 22 x 100% = 102 % (Good Nutrition)

Vital signs : Blood pressure 110/60 mmHg, pulse 88 bpm(regular,

enough content), respiratory rate 24 bpm regular,
temperature 36.6oC (axilla)

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Skin : Brownish, no efflorescence, no pigmentation, edema (-), no
swelling, low subcutaneous fat
Head and Neck
Head : Normocephaly, hair (-)
Eye : Edema palpebra -/-, conjunctiva anemis (+). Sclera non
icteric, cornea reflect +/+, pupil rounded isochor, diameter 3
mm, light reflect +/+, strabismus -/-, normal eye movement,
nistagmus -/-
Nose : Secrete -/-, redness (-)
Ear : Secrete -/-
Mouth : Sianosis (-), wet mucosa, papil tongue atrophy (-)
Throat : Tonsil T1/T1 non hiperemis, faring non hiperemis.
Neck : trachea in midline position, there were no enlargements of
lymph nodes
Chest : Symmetrical left = right, there was no retraction.

Heart
Inspection : No visible ictus cordis, no precordial bulging
Palpation : Ictus cordispalpable in left midclavicularis line, 5 th
Intercostal space, no thrill
Percussion : Left border in left midclavicularis line, right border in right
parasternalis line, upper border at 3rd left intercostal space
Auscultation : Heart rate 88 bpm, regular, pure S1 and S2, no murmur.

Lung
Inspection : symmetrical movement of breathing
Palpation : intercostal space not widen, symmetrical vocal fremitus
Percussion : normal, symmetrical resonant sounds
Auscultation :normal, vesicular breath sounds, no rales, no wheezing

Abdominal

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Inspection : flat, Venectation (-)
Palpation : flaccid abdominal wall, there were no liver nor spleen
enlargements, undulation (-), suprapubic pressure pain (-)
Percussion : tympani, no costovertebral pain
Auscultation : intestinal bowel sound was normal

Vertebra : no deformity
Genitalia : male, no deformity, palpable bilateral testicles inside the
scrotum
Extremities :no deformity, no cyanosis, warm, CRT ≤ 2, swelling around
Tibia, spastic (-), clonus (-)
Muscles :normal muscles tone on all extremities
Reflexes : normal physiological reflexes, no pathological reflexes
Sensory : normal
Motoric : normal muscles strength 5 / 5
5/5

Cranial nerves examination

NI : No olfactory problem
N II : Pupil round,isochor, light reflect +/+ normal
N III, N IV, N VI : No strabismus and ptosis, normal eye movement
NV : No disorder
N VII : Symmetrical sulcus nasolabialis, lagophtalmus (-)
N VIII : No hearing and balancing disorder
N IX : Clear articulation, swallow function was good
NX : Uvula was in central position and no deviation
N XI : Patient could shrug shoulders and turn head against
resistance
N XII : No tongue deviation.

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Resume
Patient admitted to Kandou hospital at January 27 th 2018 at 16.00
WITA to continue chemotheraphy second cycle on January 30 th 2018
Pasien had been diagnosed with acute myeloblastic from December 20 th
2017.
Patient referred from Noongan Hospital with diagnosis acute
bacterial infection and thrombocytopenia. Patient is treated in Noongan
Hospital with chief complaints fluctuated fever since 1 months before
admission. Patient also looked pale and fatique since 2 weeks before
admission. There wasn’t found spontaneous bleeding like gum bleeding,
nausea or vomiting on patient. During the hospitalization in Noongan
Hospital, patient got ceftriaxone injection. After 4 days hospitalized, patient
referred to Kandou Hospital for further examination.
Patient referred to Kandou Hospital on November 23th 2017. From
the physical examination was obtained that body weight 23 kg and height
123 cm, with good nutritional status (CDC 2000). Patient appearance was
sick, compos mentis (GCS E4V5M6). Vital sign: Blood pressure 100/70
mmHg,heart rate 120 x/m, respiration rate 24 x/minute and temperature
38,00C. In head examination, there was an anemic conjunctiva. There was
not hypertrophy gingival; There was not palpable enlargement of the
lymph nodes on the neck region. Abdomen was flat, symmetrical chest
wall movement, flaccid on palpation, liver was palpable 1 cm sub arcus
costa, lien was unpalpable. On skin there wasn’t petechiae or echimosis
Laboratory results on November 23th, 2017 Hb 10,2 g/dL, Ht 28,9
%, leukocyte 54.700/ mm3, thrombocyte 58.000 /mm3. From the blood
smear examination on November 23th, 2018 was found anemia
normocytic normochrom, normoblast (-), leukostasis, myeloid, blast (+),
thrombocytopenia, compatible with suspect acute myeloid leukemia. On
November 28th, 2018 was done bone marrow puncture (BMP) examination
to the patient. During waiting the BMP result, the patient consulted to the
cardiology division for echocardiography, otolaryngology division and

12
dentistry/oral surgery division for preparing the chemoteraphy and there
was no contraindication for chemotherapy from their division. Radiological
examination indicated normal lungs and heart. EKG indicated sinus
rhythmic.
From the BMP examination, was found anemia normositic
normochrom, eritropoiesis activation, granulopoiesis, and thrombopoiesis
is suppressed, many blast cell morphology is like myeloblast, compatible
with AML M2. From the leukemia phenothyping was found gating in blast
cell looked in CD33, CD34, CD117, HLA-DR, CD13, CD7, CD10,
compatible with myeloid lineage with aberrant exp CD7 and CD10
Patient on December 14th, 2018, admitted again to hospital to start
the chemotherapy. Patient had laboratorium control examination and was
found Hb: 8,0 gr/dL, Ht: 22,3%, Lekosit: 89.500/mm3, Trombosit:
30.000/mm3. On December 20th 2017 patient started to get
chemotheraphye 1st cycle and got Metotrexate intratechal, doxorubicin and
cytarabine for 5 days, with time and dose compatible with the protocol.
From the cerebrospinal liquor examination, BTA (-), wasn’t found bacteria
gram (+) or (-)

DIAGNOSIS
Acute Myeloblastic Leukemia (C92.00)

PROBLEM
Prognosis of patient with acute myeloblastic leukemia

MANAGEMENT PLAN
1. Diagnostic plans
- BMP and blood smear control
 2. Treatment plans
- Transfusion 5 Units of Trombocyte Concentrate
- Chemotheraphy 2nd cycle

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 - Day 1:
o Triple Intratechal (MTX 12 mg, Ara-C 40 mg,
dexamethasone 0,5 mg)
o Cytarabine 2 x 88 mg in 250 ml NaCl 0,9% iv
o Doxorubicin 26,4 mg in 250 ml Nacl 0,9% iv
- Day 2:
o Cytarabine 2 x 88 mg in 250 ml NaCl 0,9% iv
- Day 3:
o Cytarabine 2 x 88 mg in 250 ml NaCl 0,9% iv
o Doxorubicine 26,4 mg in 250 ml Nacl 0,9% iv
- Day 4:
o Cytarabine 2 x 88 mg in 250 ml NaCl 0,9% iv
- Day 5:
o Cytarabine x 88 mg in 250 ml NaCl 0,9% iv
o Doxorubicine 26,4 mg in 250 ml Nacl 0,9% iv

3. Pediatric Nutritional Care

a. Nutritional Status Assessment
8 years and 7 months old boy
Body weight : 22,5 kg
Ideal body weight : 22 kg
Height : 120 cm
Nutritional status : good (CDC 2000)
b. Determination of needs based on Recommended Daily Alowances
(RDA)
Calory = 70 kkal / kgBW / day = 1540 kkal / day
Protein = 1,0 g / kgBW / day = 22 g / day
Fat = 30% x 1540 kkal = 471 kkal = 52 g / day
Fluid = 70-85 ml/kg/day = 1540 - 1870 ml/day
c. Determining the mode of administration

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 Nutrition were given per oral
d. Determination of the type of food given
Polymeric
In the forms of:
Solid food 3x1 portions (@ 500 kkal, 4 g protein, 15 g fat)
- 3/4 glass of rice, fish, vegetablle, apple.
- Snack 2 x 100 kkal
- Mineral Water 1500 ml/day
e. Monitoring and evaluation
General state, body weight changes

4. Monitoring plans
- General state and vital signs

5. Counseling plans
Explanation about the disease, cause, course, treatment, prognosis,
complication, and long term observation.

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VIII. FOLLOW UP
28-29 January 2018 (observation day 1-2, 2nd-3rd day of
hospitalization)
S fever (-), intake (+)
O General condition : ill-looking Conciousness : compos mentis
BP : 100/60 mmHg Pulse : 84 bpm
RR : 24 cpm Temperature : 36.50C
Head : normocephal, symmetrical,
Eyes : conjunctiva anemis (+), anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : flat, flaccid, normal bowel sound
Liver and spleen unpalpated
Ekstremitas : warm, pretibial edema, CRT ≤ 2”

A Acute Myeloblastic Leukemia (CD 92.00)

P Medications:
- Transfusion Thrombocyte Concentrate 5 Units
- Pro Chemoteraphy 2nd cycle (30-01-2018):
- Triple intratechal (metotrexate 12 mg, Ara-C 40 mg,
dexamethasone 0,5 mg
- Citarabine 2 x 88 mg in 250 ml NaCl 0,9% intravena
- Doxorubicine 26,4 mg in 250 ml NaCl 0,9% intravena

Nutritional Care :
- Same as before
Plan Care: continue chemotherapy

16
 30 January 2018 (observation day 3, 4nd day of hospitalization)
S fever (-), intake (+)
O General condition : ill-looking Conciousness : compos mentis
BP : 110/60 mmHg Pulse : 90 bpm
RR : 26 cpm Temperature : 36.80C
Head : normocephal, symmetrical,
Eyes : conjunctiva anemis (+), anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : flat, flaccid, normal bowel sound
Liver and spleen unpalpated
Ekstremitas : warm, pretibial edema, CRT ≤ 2”

A Acute Myeloblastic Leukemia (CD 92.00)

P Medications:
- Chemoteraphy 2nd cycle (30-01-2018):
- Triple intratechal (metotrexate 12 mg, Ara-C 40 mg,
dexamethasone 0,5 mg
- Citarabine 2 x 88 mg in 250 ml NaCl 0,9% intravena
- Doxorubicine 26,4 mg in 250 ml NaCl 0,9% intravena
Inj. Ondansentron 2 x 4 mg iv (k/p)
Nutritional Care :
- Same as before
Plan care: continue chemotherapy

17
31 January 2018 (observation day 4, 5nd day of hospitalization)
fever (-), intake (+)
General condition : ill-looking Conciousness : compos mentis
BP : 100/60 mmHg Pulse : 88 bpm
RR : 24 cpm Temperature : 36.60C
Head : normocephal, symmetrical,
Eyes : conjunctiva anemis (+), anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : flat, flaccid, normal bowel sound
Liver and spleen unpalpated
Ekstremitas : warm, pretibial edema, CRT ≤ 2”

Acute Myeloblastic Leukemia (CD 92.00)

Medications:
- Citarabine 2 x 88 mg in 250 ml NaCl 0,9% intravena
- Doxorubicine 26,4 mg in 250 ml NaCl 0,9% intravena
- Inj. Ondansentron 2 x 4 mg iv (prn)

Nutritional Care :
- Same as before
Plan Care: continue chemotherapy

18
01 February 2018 (observation day 5, 6nd day of hospitalization)
fever (-), intake (+)
General condition : ill-looking Conciousness : compos mentis
BP : 110/70 mmHg Pulse : 84bpm
RR : 28 cpm Temperature : 37.00C
Head : normocephal, symmetrical,
Eyes : conjunctiva anemis (+), anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : flat, flaccid, normal bowel sound
Liver and spleen unpalpated
Ekstremitas : warm, pretibial edema, CRT ≤ 2”

Acute Myeloblastic Leukemia (CD 92.00)

Medications:
- Citarabine 2 x 88 mg in 250 ml NaCl 0,9% intravena
- Inj. Ondansentron 2 x 4 mg iv (prn)

Nutritional Care :
- Same as before
Plan Care: continue chemotherapy

19
02 February 2018 (observation day 6, 7nd day of hospitalization)
fever (+), intake (+)
General condition : ill-looking Conciousness : compos mentis
BP : 110/60 mmHg Pulse : 102 bpm
RR : 32 cpm Temperature : 39.20C
Head : normocephal, symmetrical,
Eyes : conjunctiva anemis (+), anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : flat, flaccid, normal bowel sound
Liver and spleen unpalpated
Ekstremitas : warm, pretibial edema, CRT ≤ 2”

Acute Myeloblastic Leukemia (CD 92.00)

Febrile Neutropenia (D 70.3)

Medications:
- Citarabine 2 x 88 mg in 250 ml NaCl 0,9% intravena
- Doxorubicine 26,4 mg in 250 ml NaCl 0,9% intravena
- Inj. Ondansentron 2 x 4 mg iv (prn)
- Inj. Ceftriaxone 2 x 1 gram iv (1)

Nutritional Care :
- Same as before

Plan: Complete Blood Count and blood culture

Laboratorium :
Hb : 8,6 gr/dL
Ht :24,2
Leukocyte: 1.400/mm3
Trombhocyte:43.000/mm3
ANC : 840
AST/ALT: 18 / U/L
Ureum/creatinin: 18/0,3 mg/dL
Sodium/Kalium/Chloride:132/4,13/98,5
Continue chemotheraphy, isolation room

20
03 February 2018 (observation day 6, 7nd day of hospitalization)
fever (+), intake (+)
General condition : ill-looking Conciousness : compos mentis
BP : 100/70 mmHg Pulse : 92 bpm
RR : 28 cpm Temperature : 37.60C
Head : normocephal, symmetrical,
Eyes : conjunctiva anemis (+), anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : flat, flaccid, normal bowel sound
Liver and spleen unpalpated
Ekstremitas : warm, pretibial edema, CRT ≤ 2”

Acute Myeloblastic Leukemia (CD 92.00)

Febrile Neutropenia (D 70.3)

Medications:
- Citarabine 2 x 88 mg in 250 ml NaCl 0,9% intravena
- Doxorubicine 26,4 mg in 250 ml NaCl 0,9% intravena
- Inj. Ondansentron 2 x 4 mg iv (prn)
- Inj. Ceftriaxone 2 x 1 gram iv (2)

Nutritional Care :
- Same as before
Plan Care: continue chemotherapy, isolation room

21
04 February 2018 (observation day 7, 8nd day of hospitalization)
fever (+), intake (+)
General condition : ill-looking Conciousness : compos mentis
BP : 100/60 mmHg Pulse : 80 bpm
RR : 24 cpm Temperature : 36,60C
Head : normocephal, symmetrical,
Eyes : conjunctiva anemis (+), anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : flat, flaccid, normal bowel sound
Liver and spleen unpalpated
Ekstremitas : warm, pretibial edema, CRT ≤ 2”

Acute Myeloblastic Leukemia (CD 92.00)

Febrile Neutropenia (D 73.0)

Medications:
- Citarabine 2 x 88 mg in 250 ml NaCl 0,9% intravena
- Doxorubicine 26,4 mg in 250 ml NaCl 0,9% intravena
- Inj. Ondansentron 2 x 4 mg iv (prn)
- Inj. Ceftriaxone 2 x 1 gram iv (3)

Nutritional Care :
- Same as before
Plan Care: continue chemotheraphy, isolation room

IX. PROGNOSIS

Ad vitam : dubia ad malam

Ad functionam : dubia
Ad sanationam : dubia ad malam

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 Observation period

Nov 27th – Dec 1st , 2017 Dec 20th – 25th , 2017 Jan 27th- 29th, 2018 Jan 30th- Feb 1st , 2018 Feb 2nd – 4th , 2018

Fever, pale, bone pain,

hypertrophy gingival (-), gum Pro chemotherapy 2nd cycle
Pro chemotherapy 1st cycle Fever (-), intake (+) Fever (+), intake (+)
bleeding (-)

GC: looked ill, CM GC: looked ill, CM GC: looked ill, CM

GC: looked ill, CM GC: looked ill, CM BP110/60 mmHg;P 88 x/m;RR 24 BP110/60 mmHg;P 90 x/m;RR 26 BP90/60 mmHg;P 102 x/m;RR
BP90/60 mmHg;P 88 x/m;RR 22 x/m;Temp: x/m;Temp: 36,6°C x/m;Temp: 36,8°C
BP100/70 mmHg;P 120 x/m;RR 32 x/m;T: 38,0°C 37,0°C 32 x/m;Temp: 39,2°C
Head: conjunctiva anemis (+) Head: conjunctiva anemis (+) Head: conjunctiva anemis (+)
Head: conjunctiva anemis (+) Head: conjunctiva anemis (+)
Abdomen: liver was palpable 1 cm sub arcus
Abdomen: liver was palpable 1 cm sub arcus costae costae
Skin: ptechiae (-)
Hb: 8,6 gr/dL
Hb: 9,9 gr/dL
Ht: 24,2%
Ht: 28,9 % Acute Myeloid Leukemia Leuko: 1.400/mm3
Hb: 10 gr/dL  Chemotherapy: Leuko: 2.300/mm3
Trombo: 43.000/mm3
- Day 1 (intratechal: metotrexate, Trombo: 25.000/mm3
Ht: 28,9% ANC: 840
araC, dexamethasone), Cytarabine ANC: 1173
Leuko: 54.700/mm3 SGOT/PT: 18/25 U/L
iv, doxorubicine iv SGOT/PT: 46/49 U/L
 Chemotherapy: Ur/Kr: 18/0,3 mg/dL
Trombo: 58.000/mm3 - Day 2 (Citarabine iv) Ur/kr: 29/0,3 mg/dL
- Day 1 (intratechal: Na/K/C : 132/4,13/98,5l
Blood smear: blast cell 72%, compatible with Acute myeloid - Day 3 (Citarabine iv and Na/K/Cl: 131/3,62/93
doxorubicine iv) metotrexate, araC,
leukemia
- Day 4 (citarabine iv) dexamethasone),
BMP: compatible AML M2 - Day 5(citarabine iv and Cytarabine iv,
Phenothyphing: myeloid lineage with aberrant exp CD7 and doxorubicine iv doxorubicine iv Acute Myeloid Leukemia
Acute Myeloid Leukemia - Day 2 (Citarabine iv)
CD10 - Day 3 (Citarabine iv and
doxorubicine iv) Febrile neutropenia

- Transfusion Thrombocyte
Acute Myeloid Leukemia concentrate 5U
- Pro chemotherapy started (30 th,  Chemotherapy:
2018) - Day 4 (citarabine iv)
- Day 5(citarabine iv and
doxorubicine iv)
Paracetamol 3 x 500 mg - 23
Ceftriaxone inj 2 x 1 gram iv
 Male, 8 year 7 month
Patient had been diagnosed with Acute Myeloblastic
CASE ANALYSIS Leukemia
Patient admitted to have chemotherapy 2nd cycle

Problem Oncology

Clinical signs & Physical Anemia, Neutropenia Thrombocytopenia, ,

examination Leukositosis

Fever, fatique

Supportive Examination Complete blood examination, ureum, creatinine, electrolyte, AST, ALT

Acute Myeloblastic Leukemia

Febrile Neutropenia
Diagnosis

Treatment Transfusion
Chemotherapy agent 24
Nutritional care

Prognosis
Characteristic of patient
Type of disease Ad vitam : dubia ad malam Education
Response to treatment Ad functionam : dubia Follow-up
Ad sanationam : dubia ad malam

1. Br J Haematol.2016;101:1359-67.(level of evidence 3B, recommendation B)

2. J Pediatr Rev. 2017;5:9182. .(level of evidence 2A, recommendation B)
3. Turk J Haematol. 2017. 34:340-44 .(level of evidence 2B, recommendation B)
4. J R Nad Med Serv. 2016. 23;59-67.(level of evidence 3B, recommendation B)

25
X. CASE ANALYSIS

Acute myeloid leukemia is a heterogenous disorder characterized by

clonal expansion of myeloid progenitors (blasts) in the bone marrow and
peripheral blood. Acute leukemia accounts for approximately 30 percent of
all childhood malignancies and is the most common cancer in children. AML
is most often seen in adults over age 40, but the annual incidence of
childhood AML is approximately 4,7 per 100.000 and is constant from birth to
10 years of age. Incidence peaks slightly in adolescence, and AML is the
more common leukemia found in neonates. Boys and girls appear to be
affected equally. It is generally reported that AML is equally distributed among
ethnic groups. 1,2,3
AML results from acquired changes in the DNA (genetic material) of a
developing marrow cell. Once the marrow cell becomes a leukemic cell, it
multiplies into 11 billion or more cells. These cells, called ‘leukemic blasts’, do
not function normally. However, they grow and survive better than normal
cells.The presence of the leukemic blasts blocks the production of normal
cells. As a result, when AML is diagnosed, the number of healthy blood cells
4,5
(red cells and platelets) is usually lower than normal.
Most patients diagnosed with AML have no clear-cut triggering event.
Repeated exposure to the chemical benzene and pestisides, can be a factor
in AML development. Benzene damages the DNA of normal marrow cells.
According to the Agency for Toxic Substances and Disease Registry, despite

26
the fact that petroleum products contribute to the majority of benzene in the
atmosphere, half of the total national personal exposure to benzene comes
from cigarette smoke. 6,7
A small but increasing percentage of AML cases arise following
treatment with chemotherapy (especially with alkylating agents or
topoisomerase II inhibitors) or radiation therapy for other cancers, such as
lymphoma, myeloma, and breast cancer. But only a small proportion of
people exposed to chemotherapy, radiation therapy and /or benzene develop
AML. A theory about why AML develops in some people is that they have
inherited genes that limit their ability to detoxify the causative agents. 6,9
Genetic disorders, such as Fanconi’s anemia, Shwachman syndrome,
Diamond-Blackfan syndrome and Down Syndrome, are associated with an
increased risk of AML. Very rarely, an unexpectedly high number of cases of
AML may be diagnosed within the same family. Clusters of AML in unrelated
8,9
people within a community are uncommon. AML is not contagious.
AML may develop from the progression of other blood cancers,
including policythemia vera, primary myelofibrosis, essential
thrombocythemia, and myelodiysplastic syndromes (MDS). 8,9
It is common for people with AML to feel a loss of well-being because
of the underproduction of normal bone marrow cells. The person may tire
more easily and have shortness of breath during normal physical
activities.People with AML may also have a pale complexion from anemia,

27
signs of bleeding caused by a very low platelet count, including black and
blue marks or bruises occurring for no reason or because of a minor injury,
the appearance of pinhead-sized red spots on the skin, called “petechiae”,
prolonged bleeding from minor cuts, mild fever, swollen gums, frequent minor
infections such as perianal sores, loss of appetite and weight loss, discomfort
in bones or joints, enlarged spleen, enlarged liver. 2,10,11
Patient is a boy, age 8 years 7 months. From the anamnesis, patient
usually contaminated with pestisides. The patient admitted to the hospital with
the chief complaint of fatigue, pale, fever, and bone pain. There’s no
symptoms and signs of spontaneous bleeding. From the physical
examination, was found enlarged liver.
An accurate diagnosis of the type of leukemia is important to estimate
how the disease will progress and determine the appropriate treatment.Some
of the the tests, may be repeated during and after therapy to measure the
effects of treatment. Blood and bone marrow tests are used to diagnose AML
and the AML subtype. A change in the number and appearance of blood cells
helps to make the diagnosis. AML cells look similar to normal immature white
cells. However, their development is incomplete. Blood and bone marrow
samples are generally taken from a vein in the patient’s arm. Samples of
marrow cells are obtained by bone marrow aspiration and biopsy. The cells
from the blood and marrow samples are examined under a microscope. In
addition to looking at the number and appearance of the cells in the blood

28
samples, the other tests will be used to confirm the diagnosis, identify the
AML subtype, and develop a treatment plan.2,10,12
The diagnosis of AML is confirmed by identifying leukemic blasts in
bone marrow samples, the percentage of blast cells at least 20 percent, AML
also can be diagnosed if the blasts have a chromosom change that occurs in
a specific type of AML even if the blast percentage is less than 20 percent,
specific chemical activity in blast cells, characteristic marker (antigens) on the
surface of blast cells, such as CD13 or CD 33(CD is an abbreviation for
“cluster designation”), cell based on the types of markers (antigens) on the
cell surface, a process called “immunophenotyping”. Flow cytometry is the
name of one test that may be used to do immunophenotyping, karyotiyping
and cytogenic analysis are processes used to identify certain changes in
chromosomes and genes. 10,12
Most people who are diagnosed with AML have one of the eight AML
subtypes based on French, American, British (FAB) classification system.2
M0 Minimally differentiated AML
M1 Myeloblasts are the dominant leukemic cells in the marrow
at the time of diagnosis
M2 Many myeloblasts, but some cells are developing toward
fully formed blood cells
M3 Leukemic cells have a translocation between chromosome
15 and 17
M4 Leukemic cells have a translocation or an inversion of
chromosome 16
29
M5 Leukemic cells have features of developing monocytes
M6 Leukemic cells have features of developing red cells
M7 Leukemic cells have features of developing platelets
Patient have some laboratory examination during hospitalization to
make sure the diagnosis. Laboratory results on November 23th, 2017 Hb
10,2 g/dL, Ht 28,9 %, leukocyte 54.700/ mm3, thrombocyte 58.000 /mm3.
From the blood smear examination was found blast cell 72%, anemia
normocytic normochrom, leukostasis, and trombhocytopenia which
compatible with Acute myeloid leukemia. From the BMP examination, was
found anemia normositic normochrom, eritropoiesis activation,
granulopoiesis, and trombopoiesis is suppressed, many blast cell morphology
is like myeloblast, compatible with AML M2. From the leukemia phenothyping
was found gating in blast cell looked in CD33, CD34, CD117, HLA-DR, CD13,
CD7, CD10, compatible with myeloid lineage with aberrant exp CD7 and
CD10.
Children who have AML are treated with an induction therapy similar to
that for adults with AML: cytarabine and drugs such as doxorubicin or
daunomycin, or a third drug such as mitoxantrone. This treatment is followed
by a complex multidrug program that results in about an 80 percent remission
rate ad a nearly 50 percent 5-year, relapse-free remission rate. 10,11,13
Patient was chemotheraphy according to Indonesian AML Protocol,
2011 and use cytarabine, doxorubicine, etoposide and intrathecal drugs
(metotrexate, ara-C, dexamethasone).

30
 During treatment for AML, the deficiency of neutrophils and monocytes
can lead to infection from bacteria and fungi normally present in the
environment, on the skin and in the nose, mouth or colon. The risk of infection
may be increased because chemotherapy damages the lining of the mouth
and intestines, making it easier for bacteria to enter the blood. When the
white cell count is low and infection risk is increased, antibiotics are given to
prevent or treat infection. 14,15
Febrile neutropenia is a condition with absolute neutrophil count (ANC)
less than 500/mm3 or less than 1000/mm3 in which potentionally decreased
into less than 500/mm3 in 48 hours.2,15
Infections that occur in the child with neutropenia should be treated
aggressively. Fever higher than 38 0C may be the only presenting sign of
infection and the child with fever and neutropenia should treated
immediatelyf. The child with fever and an ANC < 500/mm3 should be
managed as an inpatient. Following culture of blood and urine the child with
severe neutropenia and fever should receive broad spectrum parenteral
antibiotics for coverage of both Gram-positive and Gram-negative cultur
organisms.14,15
A combination of an aminoglycoside and a betalactam antibiotic is
good for initial coverage. If the child becomes afebrile, the cultures remain
negative and the clinical course improves, antibiotics may be discontinued
after 72 hours. If fever persists, other therapies, especially antifungal

31
therapies should be initiated. Patients with fever and an ANC > 1000/mm3
can generally be managed on an outpatient and treated with a beta-lactam
antibiotic such as ceftriaxone and an oral cephalosporin such as cefzil or
ceftin until all cultures are negative for 72 hours. The child who has fever and
an ANC between 500-1000/mm3 may be managed on either an inpatient or
outpatient basis, depending upon other presenting signs and symptoms such
14,15
as cough, chills, shortness of breath, or other signs of infections.
During the chemotherapy, patient got fever. From the laboratorium
examination, was found Hb: 8,6 gr/dL, Ht: 24,2%, Leukosit: 1.400/mm3,
Trombhocyte: 43.000/mm3, ANC: 840. Patient then got Ceftriaxone injection.
Ditte J.A, et al, investigated effect of age and Body Mass Index on
toxicity and survival in pediatric acute leukemiaTheir studied all patients who
completed first induction course of NOPHO-AML 2004. Children aged 10-17
years showed a trend for inferior 5 year survival compared to children aged 2-
9 years (64% vs 76%; p = 0,07). In conclusions, children aged 10-17 years
and overweight children had a higher risk of grade 3-4 toxicity. Children aged
10-17 years showed inferior survival, but unexpectedly, in this age group
overweight children tended to have increased survival. (level of evidence,
rekomendasi)16
Yousef V et al, have a metaanalysis research which aimed at
estimating the 5 year survival rates and associated factors of childhood
leukemia in Iran during 2002 to 2015.The overall 5-year survival rates in

32
patients with childhood leukemia in Iran was 0,65 (95% CI, 0,62-0,67), in the
acute lymphoblastic leukemia (ALL) subtype was 71% (95% CI: 68,0-74,0)
and in the acute myeloid leukemia (AML) subtype was 46%. Results of the
meta analysis showed significant poor survival with relapse (HR1.59 95% CI
1.27-1.98) and white blood count (WBC) counts ≥ 50.000 (HR 2.92, 95% CI
1.23-4.60). In conclusion, the results showed that 5-year survival rates in
patients with AML were lower than patients with ALL. (level of evidence,
recomendation)17
Zengin E, et al, had a research to evaluate infection-related mortality in
patients with acute myeloid leukemia (AML) treated without preventive
antibiotics and antifungals in a middle-income country. The intervention was
done to 49 pediatric patients. Four patients died during induction: one patient
due to intracranial bleeding, two patients due to thyphilitis, and one patrient
due to invasive fungal infection with pulmonary vascular invasion and
massive bleeding. Another two patients died with resistant disease. During
consolidation there were four infection-related deaths and one death due to
cardiotoxicity. Free survival and overall survival at 6 years were 42,9% and
61,2% (95% CI: 44-76 and 66-99 months). Due to considerable infection-
related deaths, antibacterial and mold-active fungal prophylaxis may be tried
during neutropenic periods in pediatric AML.(Level of
evidence,recomendation) 18

33
 Momani. A, et al, had research to assess the frequency of aberrant
antigens expression in acute leukemias and their possible prognostic
significance in a group of Jordanian patients. From 368 cases of acute
leukemia, these were 52% cases of acute myeloid leukemia, 47% cases of
acute lymphoblastic leukemia. Abberant immunophenotype expression was
observed in 23% AML cases and in 29% of ALL cases. CD7 was the
commonest aberrant lymphoid marker expressed in AML. Such aberrant
antigen expression may represent a poor prognostic indicator among this
group. These findings may help to recognize patients with high risk group and
low remission rate.(level of evidence, recommendation) 19

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