PATIENT’S RECORD

Candidate : dr. Shekina Rondonuwu

I. IDENTITY
1.1. PATIENT’S IDENTITY
Register number : 33.69.xx
Patient’s name : P.D.
Date of birth : May 8th, 2012 (5 years 2 months old)
Place of birth : Hospital
Age : Male
Nationality : Indonesia
Ethnic :M
Religion : Christian
Date of examination : 20th July 2017

1.2. PARENT’S IDENTITY

FATHER MOTHER
Name : A.P. P.H.
Age : 38 years old 29 years old
Occupation : Civil servant Physician
Education : Bachelor degree Bachelor degree

II. HISTORY
(taken from allo-anamnesis from parents and medical records at 20th July 2017 on
hemato-oncology ward
 Chief complaint : fever
 Additional complaint : pallor and bone pain

2.1 HISTORY OF PRESENT ILLNESS

 The patient was referred from a general hospital with diagnosis of suspected acute
lymphoblastic leukemia (ALL) differential diagnosed with aplastic anemia.
One week before hospital admission, the patient suffered from low grade fever,
but the temperature was not measured. Fever was recurrent, and decreased with
the administration of antipyretic. Fever usually subsided after a couple of days, but
then raised. Fever was not accompanied by colds, chills, vomit, convulsions or bowel
and urination disorders. The patient also experienced recurrent bone pain since 2
weeks before admitted to the hospital. There were no complaints of swollen joints or
previous trauma history. Then patient went to a general practitioner and was given
an antipyretic.
Three months before admitted to the hospital, the patient also had complaints of
pale. Pallor was realized by parents initially on the face then rise on the soles of both
of the hands and feet. Pale was not accompanied by signs of bleeding. Bleeding
complaints such as nosebleeds, bleeding gums or blackish-colored stool were
denied. Patient had never been exposed to pesticides, paints, gasoline, or radiation
beforehand.
On the observation for a long case, the patient had no fever, did not look pale,
and complaints of bone pain was said to have subsided. He has a good appetite.
Defecation and urination was normal. Patient was on tenth week of consolidation
phase of chemotherapy.

2.2. HISTORY OF PREVIOUS ILLNESS

 There was no history of previous illness requiring hospitalization.
 Patient barely had cough and cold, ±3 times for each year.
 The patient had diarrhea with ±2 times in recent year.
 History of food and drugs allergy was denied.

2.3. HISTORY OF ILLNESS IN THE FAMILY

No other family had blood cancer, or other disorder with the same symptoms.

2.4 HISTORY OF FAMILY’S HEALTH

  There was no exposure to cigarette smoking
 History of food and drug allergy was denied.

FAMILY TREE

STRUCTURE OF FAMILY MEMBERS

No Name Relation Gender Age
1 A.P Father M 38 years Healthy
2 P.H Mother F 29 years Healthy
3 P.D Patient M 5 years 2 months Patient
4 T.P Younger sister F 2 years Healthy

2.5. PERSONAL/ SOCIAL HISTORY

A. HISTORY OF ANTENATAL CARE
Patient was the first child of the family and was a planned pregnancy. The patient's mother
had 8 times antenatal examinations at the obstetrician. The mother had Tetanus Toxoid
(TT) immunization twice. During pregnancy the mother admitted to be healthy, had never
taking drugs, alcohol or smoking. Mother had only take vitamins from doctors during
pregnancy. History of exposure to pesticides, paints and gasoline during pregnancy was
also denied.
B. HISTORY OF LABOR
Patient was born spontaneously, aterm, birth weight 3000 grams, birth length was 50 cm,
cried immediately, at the hospital, and was assisted by obstetrician.

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

D. HISTORY OF FEEDING
The patient was given breastmilk since born until two years old, he had also given formula
milk until two years old. Milk porridge was given at six months old, then changed to
strained porridge on eight months old. He ate soft rice until 12 months old then continued
with home meals. He eats three times a day, one plate consists of rice with fish or chicken,
or eggs and vegetables.

E. 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 it was said that the growth and development of
the patient was normal. According to the mother, the growth and development of the
patient before the illness looks the same as his peers.
DEVELOPMENTAL
According to father and mother, patient’s developmental before the illness looks the same
as his peers. Said patient able to turn back body at 3 months age for the 1 st time, and
able to pronate at 5 months age for the 1st time, and already able to sat by his own without
help at 8 months old for the 1st time. At 9 months old patient able to rawl for the first time,
and at 10 months age patient already able to stand tall with holding. 1 st time patient able
to walk at 12 months age, and able to walk and run without help at 16 months age,
mumbling at 6 months age, and at 8 months age patient already able to call mother and
father.
Before the illness patient already went to school at kindergarten , and said able to keep
pace with the lessons, but since the patient got ill, patient no longer go to school.

F. HISTORY OF IMMUNIZATIONS
The patient received BCG with scar (+) on upper right arm, polio three times, DPT three
times, hepatitis B three times, measles once.

G. HISTORY OF BASIC NEEDS

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

Mental stimulation :
The patient study and play like any other at his age. Until now, the patient not go to school
yet. The patient has many friends and easy to get along with new friends.

Emotional needs :love received from parents and family. The parents accept the
patient’s illness condition. The patient received adequate care and love from parents and
family for his recovery.

SOCIO-ECONOMIC, FAMILY, INCLUDING ENVIRONTMENTAL / LIVING PLACE

Socio-Economic
The father worked as a civil servant, while his mother was a phycisian. Healthcare
expense is covered by national insurance first class.
ENVIRONTMENTAL
The patient lives with both of his parent and siblings, house with tin roof, concrete wall,
tile floor. The house consist of two bedrooms, lived by 4 person, 2 adults and 2 kids. The
bathroom/restroom 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’S TERTIARY REVERAL HOSPITAL ADMISSION SUMMARY BEFORE THE

PATIENT TAKEN AS CASE (May 7th, 2017- July 19th, 2017)
The patient first admitted to hospital on May 7 th, 2017. He was referred from regional
public hospital with diagnosis suspected acute lymphoblastic leukemia differential
diagnosed with aplastic anemia. When he was admitted to the hospital, his chief
complaint was fever, pallor and bone pain. He looked sick, fully alert. His body weight
was 17.5 kg and height 107 cm, good nutritional status according to CDC 2000 growth
chart. General condition looks sick and awareness compos mentis.Vital sign Blood
pressure was 90/60 mmHg, pulse 90 bpm (regular, full pulses), respiration rates 28 cpm,
body temperature 37.6oC. On head and neck examination, there was anemic conjunctiva,
no swelling of lymph node. In Chest examination, Cor and lung were Normal. The
abdomen looked convex, soft on palpation, with normal bowel movement sound. There
was enlargement of the liver 4-4 cm below right costal margin (BCM), with sharp edges,
flat surfaces, tender. There was also splenomegaly, measured as Schuffner III. The
extrimities looked pale, warm, and the capillary refill time was <2 seconds.
Result of laboratories workup when admitted to hospital 7 May 2017 were: haemoglobin
8.3 g/dL, hematocrite 23.9 %, leucocyte 62.800/mm3, erythrocyte 3,10 x 106/L, platelet
68.000 /mm3, MCH 26,0 pg, MCHC 33,8 g/dl, MCV 92,8 fL, C-Reactive Protein (CRP)
12mg/L, ALT 32 U/L, AST 12U/L, ureum 25 mg/dL, creatinin 0.3 mg/dL (GFR:
148.5ml/minute/1.73m2BSA), uric acid 4.9 mg/dL, albumin 3,52 g/dl, globulin 2,81 g/dl,
serum electrolytes sodium 134 mEq/L, potassium 4.5mEq/L, chloride 104 mEq/L, calcium
8.58 mg/dL, LDH 883 U/L. Pheripheral blood smear : erytrocyte was normochrome
normocytics, anisocytosis (+), poikilocytosis (+), with leucocytosis, differential count :
neutrophil 1%, lymphoblast 76%, lymphocyte 23%, monocyte 0%, conclusion: suggestive
ALL, and recommended to have a bone marrow puncture (BMP) and
immunophenotyping. Urinalysis and stool analysis within normal limits. Bone marrow
puncture was done on May 10th, 2017 and it showed a predominance of lymphoblast on
varying sizes, clear nuclei with L1 lymphoblast morphology.
Results of immunophenotyping showed gating of the blast with positive HLA-DR,
CD34, CD19, CD10, CD 20 and the impression is B lineage leukemia. Patients diagnosed
as acute lymphoblastic leukemia B lineage - high risk.
Echocardiography was done before starting the chemotherapy and the result was
normal intracardiac, no contraindication for chemotherapy. Tuberculin skin test result was
0 mm, and consultation to division of ophthalmology, otorhinolaryngology and oral health
division showed no abnormality. The x-ray examination of the thorax showed no
mediastinal mass with no heart and lung abnormalities.
On the cerebrospinal liquid examination, it was found that the liquid was cloudy,
leucocyte 188/L, glucose 62 mg/dl, Nonne and Pandy test (+), erythrocyte 0-2/hpf. This
patient was then diagnosed with acute lymphoblastic leukemia B lineage high risk and
central nervous system leukemia.
Patients started receiving chemotherapy at May 11th, 2017 using the 2013
Indonesian ALL Protocol - high risk, induction phase. During medications, the complaints
was subsided.
On the first week on induction phase, the patient had fever. On laboratory test, it
was found that haemoglobine 7.2 g/dL, hematocrite 22 %, leucocyte 1020/mm 3,
erythrocyte 3,66 x 106/L platelet 20.000 /mm3, differential count 0/0/2/15/80/3, absolute
neutrophil count (ANC) 173 cell/mm3, ALT 25 U/L, AST 35 U/L, serum electrolites sodium
137 mEq/L, potassium 3.9 mEq/L, chloride 99.2 mEq/L, calcium 8.64 mg/dL.
The patient was then diagnosed with febrile neutropenia, was admitted to isolation,
and antibiotic intravenous injections were added which was ceftriaxone and gentamycine
for 7 days and received packed red cell and thrombocyte concentrate transfusion.
On the first week on induction phase, the patient was clinically improving, the fever
diminished. The laboratory test on May 27th, 2017, it was found that haemoglobin 11.5
g/dL, hematocrite 34.8 %, leucocyte 7280/mm3, erythrocyte 3,93 x 106/L, platelet
146.000 /mm3, differential count 0/2/15/36/37/10, absolute neutrophil count (ANC) 3.712
cell/mm3, ALT 34 U/L, AST 53 U/L, serum electrolytes sodium 135 mEq/L, potassium
3.91mEq/L, chloride 98.1 mEq/L, calcium 8.76 mg/dL, ureum 34 mg/dL, creatinine 0.3
mg/dL.
On the 8th week on concolidation phase, the patient got fever. The laboratory result
on 10 July 2017 were : Hemoglobyn 6.4 g/dl, Hematocryt 21,1%, Leukocyte 4,123/ L,
thrombocyte 589.000/ L, Leucocyte differential count 0/0/20/42/32/6, ANC 2556
cell/mm3. Natrium 138 mEq/L, Potassium 4.36 mEq/L Chloride 96.3 mEq/L. and Calcium
8.56 mg/dL, SGOT 22U/L, SGPT 15 U/L, Blood Ureum 14 mg/dL, Blood Creatinin 0.4
mg/dL. The patient then admitted PC transfusion as 200mL.

Examination 07/05/2017 20/05/2017 27/05/2017

Hb (g/dl) 8,3 7,2 11,5
Ery (x106/L) 3,1 3,66 3,93
Ht (%) 23,9 20 34,8
MCV 92,8 89,2 88,2
MCH 26,0 29,2 31,2
MCHC 33,8 34 32,5
Leuco (/L) 62.800 1.020 7.280
Trombo (/L) 68.000 20.000 146.000
Diff.count (%) - 0/0/2/15/80/3 0/2/15/36/37/10
Blast (%) - 40 -
ANC (cell/mm3 ) - 173 3.712

ALT (U/L) 32 25 34
AST (U/L) 10 35 53
Ureum (mg/dl) 25 19 34
Creatinin (mg/dl) 0,3 0,2 0,3
Clorida (mEq/L) 104 99,2 98,1
Kalium (mEq/L) 4,8 3,9 3,91
Natrium (mEq/L) 134 137 135
Calcium (mg/dl) 8,58 8,64 8,76
CRP (mg/L) 12 - -
Albumin (g/dl) 3,52 - -
Globulin (g/dl) 2,81 - -
LDH (U/L) 883 - -
Uric acid 4,9 - - Stool exam :
Urinalysis : Consistency: soft
BJ 1,020 Color : yellowish
pH 7 brown
Epithel 1-2/lpb Erythrocyte (-)
Ery 0-1/lpb Epithel (-)
Leu 0-1/lpb Helminth (-)
Keton (-) Bacteria (+)
Protein (-) Protozoa (-)
Keton (-) Fungi (-)
Nitrite (-)
Examination 07/05/2017 20/05/2017 27/05/2017
Hb (g/dl) 8,3 7,2 11,5
Ery (x106/L) 3,1 3,66 3,93
Ht (%) 23,9 20 34,8
MCV 92,8 89,2 88,2
MCH 26,0 29,2 31,2
MCHC 33,8 34 32,5
Leuco (/L) 62.800 1.020 7.280
Trombo (/L) 68.000 20.000 146.000
Diff.count (%) - 0/0/2/15/80/3 0/2/15/36/37/10
Blast (%) - 40 -
ANC (cell/mm3 ) - 173 3.712

ALT (U/L) 32 25 34
AST (U/L) 10 35 53
Ureum (mg/dl) 25 19 34
Creatinin (mg/dl) 0,3 0,2 0,3
Clorida (mEq/L) 104 99,2 98,1
Kalium (mEq/L) 4,8 3,9 3,91
Natrium (mEq/L) 134 137 135
Calcium (mg/dl) 8,58 8,64 8,76
CRP (mg/L) 12 - -
Albumin (g/dl) 3,52 - -
Globulin (g/dl) 2,81 - -
LDH (U/L) 883 - -
Uric acid 4,9 - - Stool exam :
Urinalysis : Consistency: soft
BJ 1,020 Color : yellowish
pH 7 brown
Epithel 1-2/lpb Erythrocyte (-)
Ery 0-1/lpb Epithel (-)
Leu 0-1/lpb Helminth (-)
Keton (-) Bacteria (+)
Protein (-) Protozoa (-)
Keton (-) Fungi (-)
Nitrite (-)
Peripheral Erythrocyte
blood smear Normochromic Normocytics, Anisocytosis(+), Poikilocytosis (+),
(7/05/2017) Normoblast (-)
Leukosit
Extremely increasing in amount
Differensial : Eosinophil 0%, Basophil 0%, Neutrophil 23%,
Lymphocyte 23%, Monocyte 0%. Lymphoid series domination.
Lymphoblast was found ± 76%. Neutrophil looks decrease
Trombocyte
Decrease in amount. Normal morphology
Conclusion: Suspected Acute Lymhoblastic Leukemia (ALL) type I
Suggestion: BMP, leukemia phenotyping
Bone marrow Predominantly lymphoblast varying in size; minimal to moderate
examination cytoplasm; clear nucleoli : Lymphoblast L1 morphology
(10/05/2017)

Leukemia
Phenotyping Positive gating on blast area with HLA-DR, CD34, CD19, CD10,
(10/05/2017) CD20. Conclusion: B-Lineage
LCS analysis Slightly cloudy, 188 cell/L, glucose 62 mg/dl, Nonne and Pandy (+),
(11/05/2017) erytrocyte 0-2/hpf
Pemeriksaan 21/06/2017 28/06/2017 10/07/2017 19/07/2017

Hb (g/dl) 10,5 9,5 6,4 11,6

Eri (x106/L) 3,8 3,59
33,8 31,3 2,48 3,93
Ht (%)
MCV 92,8 87,1 21,2 35,7
MCH 27,7 26,5
MCHC 31,2 30,4 85,1 90,8
Leukosit (/L) 7322 3569
26,0 29,5
Trombosit (/L) 68.000 454.000
Hitung Jenis (%) 1/1/19/41/36/2 1/1/23/16/57/2 30,0 32,5
Blast (%) - -
4393 1391 4.123 4100
ANC (sel/mm3 )
589.000 558.000
Kimia Klinik
SGOT (U/L) 48 22 0/0/20/42/32/6 5/0/5/35/45/10
SGPT (U/L) 69 59
38 28 - -
Ureum (mg/dl)
Kreatinin (mg/dl) 0,3 0,3 2556 1640
Klorida (mEq/L) 101,6 93,9
Kalium (mEq/L) 4,45 3,72
Natrium (mEq/L) 138 136
Kalsium (mg/dl) 8,25 8,40
CRP (mg/L) - - 22 27
Albumin (g/dl) 3,10 -
Globulin (g/dl) 2,24 - 15 31
LDH (U/L) - -
14 30
Asam Urat - -
0,4 0,5
96,3
102,5
4,36
5,93
138
142
8,56
10,29
<6
-
-
-
-
-
 - -

- -

III. PATIENT’S DATA AND CONDITION AFTER TAKEN AS A CASE REPORT

The examination was done in pediatric hemato - oncology ward, on July 20th, 2017
Complaint: No fever, no pallor, no nose and gum bleeding, good oral intake, normal
urination, normal defecation.
General condition: ill-looking, compos mentis
Anthropometric status:
Actual bodyweight : 17.2 kg
Body height : 105 cm
Body surface area (BSA) : 0.70 m2
Weight/Age : 17.2/19 x 100% = 90 %
 Normal body weight

Height/Age : 105/110 x 100% = 95%

 Normal body height
Weight/Height : 17.2/17 x 100% = 101%
 Normal nutritional status
(Acording to CDC 2000 stature for age and weight for age percentiles, boys age 2-
20 years)

Vital signs : Blood pressure 90/60 mmHg, pulse 98 bpm

(regular, enough content), respiratory rate 28
cpm, body temperature 36.8°C (axilla)
Skin : Light brown colored, no signs of hemorrhage, no
efflorescent, no scars, no pigmentation, BCG scar appeared
on upper right arm, no swelling, low subcutaneous fat

Head and Neck

Head : closed fontanel, strong black hair, no alopecia, moon face
Eyes : no palpebral edema, pink conjunctivae, anicteric sclerae, round
and isochoric pupils with diameter of 3-3 mm, reactive to light,
centered eyeballs, clear lenses, good eye movements to all
directions, no nystagmus.
Nose : no deformity, midline septum, no secretion, no nasal flaring.
Ears : well-curved pinna, no deformity, no fluid secretion, intact tympanic
membranes.
Mouth : no cyanosis, moist mucosa, no atrophy of tongue papillae,
symmetrical nasolabial sulci, no teeth carries, no stomatitis.
Throat : tonsils T1/T1 not hyperemic, pharynx not hyperemic.
Neck : centered trachea, no palpable lymph node enlargement, no nuchal
rigidity, JVP not increase.
Chest : normal shape, symetrical chest expansion, no retraction.

Heart
Inspection : no visible ictus cordis, no precordial bulging.
Palpation : ictus cordis palpable in left midclavicle line, 5th intercostal space,
no thrill.
Percussion : right border at right parasternal line, left border at left midclavicle
line, upper border at 3rd left intercostal space.
Auscultation : heart rate frequency 88 bpm, regular, pure S1 and S2, no murmur.

Lungs
Inspection : symmetrical movement of breathing
Palpation : intercostal spaces not wide, symmetrical vocal fremitus
Percussion : normal, symmetrical resonant sounds
Auscultation : normal, vesicular breath sounds, no rales, no wheezing

Abdomen
Inspection : flat
Palpation : soft, palpable liver 1-1 cm below costal line, dull edges, flat surface,
tender, no tenderness. Spleen: Schuffner I
Percussion : tympanic, no costovertebral pain.
Auscultation : normo-active bowel sounds.

Vertebrae : no deformity
Genitalia : male, no deformity, palpable bilateral testicles inside the scrotum.
Extremities : no deformity, no cyanosis, warm, CRT ≤ 2 seconds, no swelling.
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 = round, isochoric pupils, positives direct and indirect light reflexes
N III, IV, VI = no strabismus, normal movements of the eyeballs
NV = no problem
N VII = symmetrical nasolabialis sulci, no lagophtalmus
N VIII = no hearing or balance problem
N IX = clear articulations, can swallow well
NX = uvula is central, no deviation
N XI = can shrug shoulders and turn head against resistance
N XII = no tounge deviation

IV. SUMMARY
The patient first admitted to hospital on May 7th, 2017. He was referred from regional
public hospital with the diagnosis of suspected acute lymphoblastic leukemia and
differential diagnosed with aplastic anemia. When he was admitted to the hospital, his
complaint was fever, pallor and bone pain. On first physical examination, the patient
looked ill and fully alert. Patient’s body weight was 17.2 kg with height of 105 cm. The
patient has good nutritional status according to CDC growth chart. Blood pressure was
90/60 mmHg, pulse 98 bpm (regular, full pulses), respiration rates 28 cpm, body
temperature 36.8oC (axilary). On head and neck examination, anemic conjunctiva was
found and no palpable lymph nodes enlargement. On chest examination, the heart and
lung was in normal range. The abdomen looked flat, soft on palpation, with normal bowel
movement sound. There was enlargement of the liver 4 cm below right costal margin
(BCM) and 4 cm below xyphoid process, with sharp edges, flat surface, tender. There
was also splenomegaly, measured as Schuffner III. The extremities looked pale, warm,
and the capillary refill time was < 2 seconds.
 Result of laboratories workup when admitted to hospital were: haemoglobin 8.3
g/dL, hematocrite 23.9 %, leucocyte 62800/mm3, erythrocyte 3.10 x 106/L, platelet
68000 /mm3, MCH 26.0 pg, MCHC 33.8 g/dl, MCV 92.8 fL, ALT 32 U/L, AST 10 U/L,
ureum 25 mg/dL, creatinin 0.3 mg/dL, chloride 104 mEq/L, potassium 4.5mEq/L, sodium
134 mEq/L, calcium 8.58 mg/dL, uric acid 4.9 mg/dL, LDH 883 U/L. Urinalysis and stool
analysis within normal limits. Peripheral blood smear: erytrocyte was normochrome
normocytics, anisocytosis (+), poikilocytosis (+), with leukocytosis, differential count:
neutrophil 1%, basophil 0%, eosinophil 0%, lymphoblast 76%, lymphocyte 23%,
monocyte 0%, conclusion: suggestive ALL, and recommended to have a bone marrow
puncture (BMP) and immunophenotyping. On that moment, the patient was treated with
intravenous hyperhydration with observed urinalysis, antibiotic and oral paracetamol was
also given to the patient. Supportive nutritional care with normal diet based on
recommended daily allowance (RDA).
Bone marrow puncture was done on May 10th, 2017 and it showed a predominance
of lymphoblast on varying sizes, clear nuclei with L1 lymphoblast morphology. Results of
immunophenotyping showed gating of the blast with positive HLA-DR, CD34, CD19,
CD10, CD 20 and the impression is B lineage leukemia. Patients diagnosed as acute
lymphoblastic leukemia B lineage - high risk.
The patient was planned for chemotherapy after completing the necessary workup.
Echocardiography result was normal intracardiac with no contraindication for cytostatic
drugs. The patient chest X-Ray showed no abnormality. Tuberculin skin test result was 0
mm, and consultation to division of ophthalmology, otorhinolaryngology and oral health
division showed no abnormality. On the cerebrospinal liquid examination, it was found
that the liquid was cloudy, leucocyte 188/L, glucose 62 mg/dl, Nonne and Pandy test
(+), erythrocyte 0-2/hpf. This patient was then diagnosed with acute lymphoblastic
leukemia B lineage high risk and central nervous system leukemia.
The patient started receiving chemotherapy on May 11th, 2017 based on modified
2013 Indonesian high risk ALL and CNS leukemia Protocol. During the medication, the
complaints was subsided.
On the first week of induction phase, the patient had fever. The laboratory testing
on Mei 20th, 2017 had the following results: haemoglobin 7.2 g/dL, hematocrite 22 %,
leucocyte 1020/mm3, erythrocyte 3,66 x 106/L platelet 20000 /mm3, leucocyte differential
count 0/0/2/15/80/3, absolute neutrophil count (ANC) 173 cell/mm3, ALT 25 U/L, AST 35
U/L, serum electrolites sodium 137mEq/L, potassium 3.9 mEq/L, chloride 99.2 mEq/L,
calcium 8.64 mg/dL. On peripheral blood smear, 40% blast cell still found. The patient
was then diagnosed with febrile neutropenia and transferred to isolation ward. Ceftriaxone
and gentamicin was injected intravenously for 7 days. Packed red cell and thrombocyte
concentrate transfusion was also given as needed.
On the week eight of consolidation phase, the patient had fever. The laboratory
testing on July 10th, 2017 had the following results: haemoglobin 6.4 g/dL, hematocrite
21.1 %, leucocyte 4123/mm3, erythrocyte 2.48 x 106/L, platelet 589000 /mm3, leucocyte
differential count 0/0/20/42/32/6, absolute neutrophil count (ANC) 2556 cell/mm3, ALT 22
U/L, AST 15 U/L, ureum 14 mg/dL, creatinine 0.4 mg/dL, serum electrolites sodium 138
mEq/L, potassium 4.36 mEq/L, chloride 96.3 mEq/L, calcium 8.56 mg/dL. The patient was
then transfused with 200 ml PRC.

V. DIAGNOSIS
 Acute lymphoblastic leukemia, B lineage high risk (C91.01)
 Central nervous system leukemia (C91.00)

VI. LIST OF PROBLEMS

 Prognosis of a 5 years and 2 months old boy with high risk B-Lineage ALL on
induction phase and central nervous system leukemia.

VII. MANAGEMENT PLANS

1. Treatment plans
- Chemotherapy according to modified 2013 Indonesian Protocol for high risk
ALL
- Complete blood count

2. Pediatric nutritional care

 a. Nutritional status assessment
5 years and 2 months old boy
Body weight : 17.2 kg
Ideal body weight : 17 kg
Height : 15 cm
Nutritional status : good (CDC 2000)

b. Determination of needs based on Recommended Daily Allowances (RDA)

Calories need = 90 kcal/kg/day = 1530 kcal/day
Proteins need = 1.2 g/kg/day = 20.4 g/day
Fats need = 30% x 1.548 kkal = 51 g/day
Fluid need = 90-110 ml/kgBB = 1530 -1870 mL/day
c. Determining the mode of administration
Nutritions were given per oral

d. Determination of the type of food given:

Polymeric
In the forms of:
Solid food 3 x 1 portions (@ 375 kcal, 12 g of protein, 10 g of fat)
 ¾ cup of rice, 1 cup of green beans, egg, 1 apple.
 2 biscuit snacks (@ 43 kcal, 10 g of carbohydrate)
 2 glasses of milk, 200 ml (@140 kcal, 5 g of protein, 6 g of fat)
Mineral water 1100 - 1400 ml/day

e. Monitoring and evaluation

Periodical monitoring of acceptability, food tolerance, and body weight change.

3. Counseling plans
 Natural history of the disease, side effects of the chemotherapy, and prognosis
 Immunization plan after chemotherapy
4. Monitoring plans
 General state, vital signs, anthropometry.
 Side effects administration of chemoteraphy.
 Nutritional monitoring.
 Monitoring of therapy, evaluation of the therapeutics response, side effects of
the therapy, ie. gastrointestinal side effects, and long term monitoring of the
side effects of the therapy such as hepatitis, optic neuritis, peripheral neuritis.
 Monitoring of the development
 Supervision of hygiene for parents, caregiver and medics.

5. Education Plan
 Describes the illnesses of the patient: causes, treatment, prognosis,
complications and treatment plans.
 Educate the family members about importance of family support for patient
recovery.
 Educate the impact on the child's social life, and family economic situation
because of long-term treatment.
 Education to maintain personal hygiene and avoid the environment situation
that can cause infection.
Education on immunization plans for patients after chemotherapy is complete
VII. PATIENT’S FOLLOW UP AFTER TAKEN AS A CASE REPORT

21st July 2017 (Observation day 1, 3rd day of hospitalization)

S Fever (-), joint pain (+), pallor (-), nausea (-), vomitting (-), intake (+)
O General condition : ill-looking Conciousness : compos mentis
BP : 90/60 mmHg Pulse : 98 bpm
RR : 28 cpm Temperature : 36.8 0C
BW : 17.2 kg Height : 105 cm
BSA : 0.70
Head : normocephal, symmetrical, moon face (+)
Eyes : pink conjunctivae, anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : convex, soft, normal bowel sound
Liver palpable 1-1 cm bac, spleen Schuffner I
Ekstremitas : warm, CRT ≤ 2”
A  Acute lymphoblastic leukemia, B lineage high risk (C91.01)
 Central nervous system leukemia (C91.00)
P Medications:
- High dose MTX 710 mg in 50 cc NaCl 0.9%, 20-21 gtt/m (until 10
a.m local time)
- Leucovorin 10.65 mg in 250 cc NaCl 0.9% (3x)
- 6MP 1 x ¾ tab P.O

Nutritional care:
Solid food 3 x 1 portions (@ 375 kcal, 12 g of protein, 10 g of fat)
 ¾ cup of rice, 1 cup of green beans, egg, 1 apple.
 2 biscuit snacks (@ 43 kcal, 10 g of carbohydrate)
 2 glasses of milk, 200 ml (@140 kcal, 5 g of protein, 6 g of fat)
Mineral water 1100 - 1400 ml/day
 Workup plan:
ALT, AST post leucovorin treatment

22nd July 2017 (Observation day 2, 4th day of hospitalization)

S Fever (-), joint pain (+), pallor (-), nausea (-), vomitting (-), intake (+)
O General condition : ill-looking Conciousness : compos mentis
BP : 90/60 mmHg Pulse : 92 bpm
RR : 28 cpm Temperature : 36.5 0C
BW : 17.2 kg Height : 105 cm
BSA : 0.70
Head : normocephal, symmetrical, moon face (+)
Eyes : pink conjunctivae, anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : convex, soft, normal bowel sound
Liver palpable 1-1 cm bac, spleen Schuffner I
Ekstremitas : warm, CRT ≤ 2”
Laboratory
Hemoglobin: 10.2 g/l Ureum: 14 mg/dl
Erythrocyte: 3.68 x 106/L Creatinine: 0.2 mg/dl
Hematocrit: 32.4 % Chloride:100 mEq/L
Leucocyte: 3900 /L Potassium: 4,3 mEq/L
Platelet: 675000 /L Sodium: 135 mEq/L
Differential count: 0/4/48/40/6 ANC: 1879
AST: 27 U/L ALT: 26 U/L
A  Acute lymphoblastic leukemia, B lineage high risk (C91.01)
 Central nervous system leukemia (C91.00)
P Medications:
- Leucovorin 10.65 mg in 250 cc NaCl 0.9% (3x)
 Nutritional care:
Solid food 3 x 1 portions (@ 410 kcal, 15 g of protein, 50 g of fat)
 ¾ cup of rice, 5 medium sized meat balls, 1 medium slice of beef, 1
cup of chayote, 1 orange.
 2 glasses of milk, 200 ml (@140 kcal, 5 g of protein, 6 g of fat)
Mineral water 1100 - 1400 ml/day

23rd July 2017 (Observation day 3, 5th day of hospitalization)

S Fever (-), joint pain (+), pallor (-), nausea (-), vomitting (-), intake (+)
O General condition : ill-looking Conciousness : compos mentis
BP : 90/60 mmHg Pulse : 94 bpm
RR : 28 cpm Temperature : 36.6 0C
BW : 17.2 kg Height : 105 cm
BSA : 0.70
Head : normocephal, symmetrical, moon face (+)
Eyes : pink conjunctivae, anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : convex, soft, normal bowel sound
Liver palpable 1-1 cm bac, spleen Schuffner I
Ekstremitas : warm, CRT ≤ 2”
A  Acute lymphoblastic leukemia, B lineage high risk (C91.01)
 Central nervous system leukemia (C91.00)
P Medications:
- 6MP 1 x ¾ tab P.O

Nutritional care:
Solid food 3 x 1 portions (@ 350 kcal, 5 g of protein, 10 g of fat)
  ¾ cup of rice, 1 medium slice of fried fish, 1 cup of chayote, ½
glasses of coconut milk.
 2 apples (@50 kcal, 12 g of carbohydrate)
 2 biscuit snacks (@43 kcal, 1 g of protein, 10 g of carbohydrate)
 2 glasses of milk, 200 ml (@140 kcal, 5 g of protein, 6 g of fat)
Mineral water 1100 - 1400 ml/day

24th July 2017 (Observation day 4, 6th day of hospitalization)

S Fever (-), joint pain (-), pallor (-), nausea (-), vomitting (-), intake (+)
O General condition : ill-looking Conciousness : compos mentis
BP : 90/60 mmHg Pulse : 100 bpm
RR : 28 cpm Temperature : 36.5 0C
BW : 17.2 kg Height : 105 cm
BSA : 0.70
Head : normocephal, symmetrical, moon face (+)
Eyes : pink conjunctivae, anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : convex, soft, normal bowel sound
Liver palpable 1-1 cm bac, spleen Schuffner I
Ekstremitas : warm, CRT ≤ 2”
A  Acute lymphoblastic leukemia, B lineage high risk (C91.01)
 Central nervous system leukemia (C91.00)
P Medications:
- 6MP 3 x ¾ tab P.O

Nutritional care:
Solid food 3 x 1 portions (@ 425 kcal, 11 g of protein, 23 g of fat)
  ¾ cup of fried rice (@ 275 kcal, 4 g of protein, 10 g of fat, 40 g of
carbohydrate), ½ medium slice of sausage (@ 150 kcal, 7 g of
protein, 13 g of fat).
 2 sweet oranges (@50 kcal, 12 g of carbohydrate)
 1 glasses of milk, 200 ml (@140 kcal, 5 g of protein, 6 g of fat)
Mineral water 1100 - 1400 ml/day

25th July 2017 (Observation day 5, 7th day of hospitalization)

S Fever (-), joint pain (-), pallor (-), nausea (-), vomitting (-), intake (+)
O General condition : ill-looking Conciousness : compos mentis
BP : 100/60 mmHg Pulse : 98 bpm
RR : 28 cpm Temperature : 36.8 0C
BW : 17.2 kg Height : 105 cm
BSA : 0.70
Head : normocephal, symmetrical, moon face (+)
Eyes : pink conjunctivae, anicteric sclerae
Neck : no lymph node enlargement
Chest : symmetrical movement, no retraction
Heart, Lung : normal limit
Abdomen : convex, soft, normal bowel sound
Liver palpable 1-1 cm bac, spleen Schuffner I
Ekstremitas : warm, CRT ≤ 2”
A  Acute lymphoblastic leukemia, B lineage high risk (C91.01)
 Central nervous system leukemia (C91.00)
P Medications:
- 6MP 3 x ¾ tab P.O

Nutritional care:
Solid food 3 x 1 portions (@ 350 kcal, 12.5 g of protein, 17 g of fat)
  ¾ cup of rice (@ 175 kcal, 4 g of protein, 40 g of carbohydrate), fried
chicken (@150 kcal, 7 g of protein, 12 g of fat), ½ cup of bean
sprouts (@ 25 kcal, 1.5 g of protein, 5 g of carbohydrate)
 2 quarter of pineapples (@50 kcal, 12 g of carbohydrate)
 2 glasses of milk, 200 ml (@140 kcal, 5 g of protein, 6 g of fat)
Mineral water 1100 - 1400 ml/day

VIII. PROGNOSIS

o Ad Vitam : dubia ad malam

o Ad Functionam : dubia ad malam
o Ad Sanationam : dubia ad malam