MORTALITY REPORT

A 13 YEARS 9 MONTHS OLD BOY WITH 8TH DAY FEBRILE

OBSERVATION DD/ MALIGNANCY DD/ INFECTION DD/
AUTOIMMUNE, OBESITY, HYPERTENSION STAGE I,
HYPERLIPIDEMIA, BICYTOPENIA OBSERVATION,
SUSPICION OF METABOLIC SYNDROME

Night Shift Residents:

Tuesday, April 16th 2019
I : dr. Tantri Infection Residents:
PICU : dr. Amal dr. Puspita
NICU : dr. Icha dr. Octrie Tamara
RSND : dr. Yuni dr. Yeni Konga
PBRT 1 : dr. William dr. Lauren Harinda
PBRT 2 : dr. Lia dr. Fitri Amalia
ER : dr. Novel dr. Kartika Istiningtyas
HCU : dr. Trisy dr. Irkania Prasangka
IV+A : dr. Yeni
IV+B : dr. Ifa
IV- : dr. Fendy Infection Supervisors:
V+ : dr. Vivi dr. MMDEAH Hapsari, SpA(K)
ER jr : dr. Nita dr. Nahwa Arkhaesi, Msi. Med, SpA (K)
V-A : dr. Hefira dr. Helmia Farida, M.Kes, SpA, PhD
V-B : dr. Hali

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I. IDENTITY Eye : Anemic Palpebral Conjungtival (-/-), Icteric sclera (-/-),
Name : AIBW Isokor pupil 2mm/2mm, Light reflex (+/+)
Date of birth/Age : Juny 20th, 2005/13 Years 9 Months Nose : flaring nostril (-), discharge (-)
Charged Date : April 14th, 2019 Ear : discharge (-/-)
Death time : April 16th, 2019 Mouth : cyanosis (-)
Thorax : symmetric, retraction (-)
ANAMNESIS Cor : heart sound I-II normal, murmur (-), gallop (-)
Chief complaint: Fever Pulmo : Vesicular +/+ +/+
Present Medical History: Ronchi -/- -/-
± 8 days prior to admission patient was complaint fever, the Wheezing -/- -/-
temperature was not measured with thermometer, fever was getting better Abdomen : Flat, supple, Abdominal sound (+) normal
by administration of paracetamol but then the temperature was going up Liver : not palpable
again, reddish spot appears for 2 days and then disappear. Spleen : not palpable
± 4 days prior to admission, patient was complaint nose bleeding Extremity : Warm +/+ +/+
once approximately 5-10cc, and spontaneously stopped. Patient was also Cyanosis -/- -/-
complaining for knee pain for 1 month. There was no cough, no flu. CRT <2” <2”
± 3 days prior to admission, the patient was brought to doctor and Edema -/- -/-
did blood test. The laboratory results revealed trombocytopenia and the
patient was suspected with dengue fever. The patient was brought to the Further Diagnostic Examination
general hospital in Salatiga. During the hospitalization in Salatiga, he was Patra Medica Clinic
given one bag of PRC and three bags of platelet transfusion. The patient was Examination Standard Denomination 10/4
reffered to Kariadi Hospital. Hematology
Hemoglobin 10.5 – 15 g/ dL 10.7
Past Medical History: Hematocrit 36 – 44 % 29.6
There is no history of similar complaint Erythrocytes 3 – 5.4 10^6/ uL 3.71
MCH 23.00-31.00 Pg 30.3
Family Medical History: MCV 77 – 101 fL 79.7
There is no family member with a history of similar complaint MCHC 29.0 – 36.0 g/dL 38.0
Leukocytes 5 – 13.5 10^3/uL 16.12
Physical Examination on March 13st, 2019 (Emergency room, 20.41) Thrombocytes 150 – 400 10^3/uL 30
General Condition : ill appearance
Clinical Chemistry
Consciousness : compos mentis
Uric acid 3.5 – 7.2 Mg/dL 10.7
Body Weight : 105 kg (ideal body weight 60kg), : Height 180 cm
Triglyceride 30 – 100 Mg/dL 638
HR : 113 bpm N : regular, adequate volume and pressure
Cholesterol 121 – 203 Mg/dL 282
RR : 24 times/minute t : 36,2 °C (axillar) BP : 160/90 (>P95+12)
Direct LDL < 130 Mg/dL 144.8

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 Blood glucose 70 – 115 mg/dL 78 Pathology 0.0 – 0.5 /ul Negative
Rheumatoid (-) cylinder
Factor Epitel cylinder Neg /LPF 0-1/LPK
ASTO (+) Erythrocyte Neg /LPF 0-1/LPB
TSHs 0.51 – 4.94 uIU/mL 5.20 cylinder
Leucocyte Neg /LPF 0-1/LPB
In Salatiga General Hospital cylinder
Examination Standard Denomination 10/4 11/4 12/4 13/4 Bacteria 0-100 /uL Negative
Hematology Sperm 0.00 – 3.00 /ul Negative
Hemoglobin 10.5 – 15 g/ dL 9.6 8.4 8.4 7.3
Hematocrit 36 – 44 % 28.3 25.5 26.3 23.3 In Kariadi General Hospital
Erythrocytes 3 – 5.4 10^6/ uL 3.48 3.11 3.19 2.85 13/4/19
Examination Standard Denomination
MCH 23.00-31.00 Pg 27.5 27.0 26.3 25.6 22.20
MCV 77 – 101 fL 81.5 82.1 82.5 81.8 Hematology
MCHC 29.0 – 36.0 g/dL 33.9 32.9 31.9 31.3 Hemoglobin 10.5 – 15 g/ dL 7.7
Leukocytes 5 – 13.5 10^3/uL 10.1 9 6.6 7.2 Hematocrit 36 – 44 % 22.1
Thrombocyte 150 – 400 10^3/uL 39 15 24 18 Erythrocytes 3 – 5.4 10^6/ uL 2.81
RDW 11.6 – 14.8 % 16.5 13.4 13.2 13.6 MCH 23.00 – 31.00 Pg 27.4
MPV 4.00 – 11.00 fL 11.9 7.5 7.5 8.7 MCV 77 – 101 fL 78.6
MCHC 29.0 – 36.0 g/dL 34.8
Urine Routine (11/4/2019) Leukocytes 5 – 13.5 10^3/uL 9.8
Urine Routine Standard Denomination 11/4/19 Thrombocytes 150 – 400 10^3/uL Clumping (++),
Colour Yellow fibrin (+)
Purity Cloudy RDW 11.6 – 14.8 % 18.2
Mass 1.003 – 1.025 1.015 MPV 4.00 – 11.00 fL -
pH 4.8-7.4 6.0 Clinical Chemistry
Protein Neg mg/dl Positive 1 Blood glucose 80 – 160 mg/dL 98
Glucose Normal Ureum 15 – 39 mg/dL 16
Reduction Neg mg/dL Negative Creatinin 0.60 – 1.30 mg/dL 0.51
Urobilinogen Neg mg/dL Normal Calcium 2.12 – 2.52 Mmol/L 2.31
Bilirubin Neg mg/dL Negative Natrium 136 – 145 Mmol/L 138
Aseton Neg mg/dL Negative Kalium 3.5 – 5.1 Mmol/L 5.0
Nitrit Neg Negative Chlorida 98 – 107 Mmol/L 96
Crystal Amorf uric (+4) CRP 0 – 0.30 Mg/dL 38.13

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 ASTO Positive - Suspect Metabolic Syndrome

Therapy :
- Infus D5 ½ NS 720/30ml/hour
Diagnosis : - Paracetamol tablet 500mg/4-6hour (t>38oc)
- Obs. Fever day 8 DD/ infection dd/ urinary tract infection
DD/ non infection dd/ malignancy, autoimmune Programs :
- Obesity - Consult to nephrology division (in ward)
- Hypertension stage II - Consult to nutrition division (in ward)
- Hyperlipidemia - Consult to hematology division (in ward)
- Hyperuricemia
- Obs. Bicytopenia

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HISTORY OF THE DISEASE

Date/Time Sign and Symptoms, Further Exam Assessment Therapy, Program, Diet, Program
Parkit Receive new patient from the emergency room - Obs. Fever day 8 - Infusion D5 ½ NS 720/30ml/hour
14/04/2019 dd/ non infection Per Oral:
09.00 dd/ hematology - Paracetamol tab 500mg/4-6hour (t > 38oC)
Day : 1 malignancy
dd/ infection PROGRAM:
10.50 Calling dr. Nahwa about new patient, advice: dd/ suspect urinary tract - Anterior tampon 2 x 24 hours (advice from ENT) for epistaxis
- Consult to division of nephrology, nutrition, and infection - Consult and referred main leader to hematology
hematology - Hypertension stage I - Consult to nephrology division
- Check blood culture, urine routine - Overweight, tall stature - Consult to nutrition division
- Laboratory test : haematology - Obs. Bicytopenia - Wait for the result of blood cultures (14/3/19)
- Measure ideal body weight - Check urine routine and urine cultures  wait for sample

12.50 Calling dr. Nahwa about epistaxis, advice:

- Consult ENT division

14.15 Calling dr. Nahwa, told that the patient had

epistaxis and critical laboratory
Hb: 7.9; Leu: 8.100; Platelets: 16.000
Advice:
- Referred main leader to hematology (in
collaboration with division of infection) and
approve for blood transfusion if it is required

14.15 S: fever (+), headache (-), nausea (-), vomitus (-)

O: general conditions: alert
HR : 110x/bpm N : regular, adequate
RR : 24x/minute t : 37 oC
SpO2 : 98% TD : 140/90 mmHg
Eye : anemic (-/-), icteric (-/-)
Nose : nose flaring (-), epistaxis (+) (with tampon)
Mouth : cyanosis (-)
Thorax : symmetric, retraction (-)
Cor : heart sound I-II normal, murmur (-), gallop (-)

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 Pulmo : SD vesicular +/+ +/+ ronchi -/- -/-
wheezing -/- -/-
Abdomen : flat, supple, abdominal sound (+) normal,
liver dan spleen not palpabe
Extremity : Warm extremities +/+ +/+
Cyanosis -/- -/-
CRT <2”/<2” <2”/<2”

14.30 Advice from ENT Division

Interpretation:
- Anterior epistaxis ec trombocytopenia
Suggestion:
- Attached anterior tampon (for 2 x 24hours)
- Attached the kassa in front of the nose
- Trombocyte correction

Advice from Nutrition and Metabolic Division

16.00 Interpretation:
- Overweight, tall stature
- Obs. Fever day 8 dd/ non infection dd/ malignancy
- Hypertension stage I
Suggestion :
- Infusion D5 ½ NS 720/30ml/hour
- Low salt rice 3 x 1
- Fruit 2 x 1
- Skim milk 3 x 200ml
- Suggest: check lipid profile (fasting 12 hours before)

16.30 Response from Nephrology Divison

Interpretation:
- Fever day 8 DD/ non infection dd/ malignancy dd/ autoimmune
DD/ infection
- Hypertension stage I, history of hypertension crisis
- Overweight, tall stature
- Dyslipidemia, metabolic syndrome
Suggestion:
- Captopril 6,25mg/24hour  12,5mg/8hour
- USG abdomen

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 - Check urine routine, urine cultur, albumin

17.00 Advice from Hematology Divison (confirmed 15/4/19 10.00)

Interpretation:
- Fever day 8 DD/ non infection dd/ hematology malignancy dd/
autoimmune
DD/ infection dd/ suspect urinary tract infection, DHF
- Obs. Bicytopenia
- Hypertension stage I
- Overweight, tall stature
Suggestion:
- Check for peripheral blood picture, diff count
- Check for reticulocytes
- Check for DsDNA
- Check for urine routine

23.00 S: fever (-), nose tampon leak - Obs. bicytopenia - Advice from dr. Nahwa SpA 
O: general conditions: awake PRC transfusion 750cc (250cc; 250cc; 250cc)
HR : 105x/minute N : regular, adequate Check dengue blot IgG and IgM
RR : 24x/minute t : 36,8 oC
PROGRAM:
- Wait for the result of diff count and peripheral blood smear
- Wait for the response from hematology division
- Check urine routine, urine cultures, albumin, USG abdomen, chect x
ray imaging ~ nephrology division
- Evaluation of general condition, vital sign, haemorrhage
Parkit S: fever (-), headache, no blood flows actively through - Prolonged fever dd/ non - Infusion D5 ½ NS 1200/50ml/hour
15/04/2019 tampon, nausea (-), vomitus (-), urination and infection dd/ malignancy, - Inj. Ampicillin sulbactam 1,5gr/8hours intravena
06.00 defecation is normal. The patient had a history of autoimmune Per Oral:
Day : 2 subfebrile fever and knee pain for 1 month dd/ infection dd/ suspect UTI - Paracetamol tab 500mg/4-6hour (t > 38oC)
O: general conditions: awake - Anterior epistaxis - Captopril 12,5mg/8hour
HR : 110x/minute N : regular, adequate - Hypertension stage I with
RR : 24x/minute t : 36,3oC history of hypertension crisis PROGRAM:
SpO2 : 90-95% TD : 140/80 mmHg - Obs. Bicytopenia dd/ - Wait the result of blood cultures and urine cultures (14/4/19)
Eye : anemic (-/-), icteric (-/-) hematologic malignancy - Wait the result of diff count and peripheral blood picture (14/4/19),
Nose : nose flaring (-), anterior tampon attached, leak to comorbid epistaxis dengue blot (14/4/19)
the kassa (+) - Hypoalbuminemia (2.8) - USG abdomen (15/4/19 at 09.00)
Mouth : cyanosis (-), gingiva haemorrhage (-) - Overweight, tall stature - Wait the response from consultation and referred main leader from
Thorax : symmetric, retraction (-) hematology division

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Cor : heart sound I-II normal, murmur (-), gallop (-) - Dyslipidemia dd/ metabolic - In collaboration with division of nephrology and nutrition
Pulmo : SD vesicular +/+ +/+ ronchi -/- -/- syndrom - PRC transfusion (250ml; 250ml; 250ml)
wheezing -/- -/- e - Suggestion from nutrition division: check lipid profile (fasting 12
Abdomen : flat, supple, abdominal sound (+) normal, hours)
liver dan spleen not palpabe - Diet: low salt rice 3 x 1, fruit 2 x 1, skim milk 3 x 200ml
Extremity : Warm extremities +/+ +/+ - Check lipid profile (fasting 12 hours before  15/4/19 6p.m. until
Cyanosis -/- -/- 16/4/19 6a.m)
CRT <2”/<2” <2”/<2”
Petechiae -/- -/-
Hematom -/- -/-

Diff Count order date 13/4/19, finish date 15/4/19

E1/B0/Bt1/S10/L62/M2
Myelocyte 2%, AMC 17%, blast 5%, nucleated
erythrocyte: 5/100 leucocytes, LPB = 2/100 leucocytes
Peripheral Blood Smear order date 13/4/19, finish
date 15/4/19
Erythrocytes: the distribution seems loose, mild
anisocytosis, mild poicilocytosis
Chemical Clinic 15/4/19
Albumin: 2.8
Serology 15/4/19
Dengue IgG: (-)/negative
Dengue IgM: (-)/negative
Coagulation Study 15/4/19 at 13.20
Prothrombin time: 15.5
PPT control: 11.2
Thromboplastin time: 29.1
APTT control: 32.2
Chest X Ray Imaging AP Semierect (Less
Inspiration) – Lateral 15/4/19
Interpretation:
- Cor not enlarged
- There is no abnormal imaging in pulmo
USG Abdomen 15/4/19
Interpretation:
- Hepatomegaly
- Splenomegaly with widening of the splenic vein

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 10.00 Approval from Division of Hematology to be main Advice :
leader of this patient . Check diffcount, pheriperal blood smear, coagulation study, ds-
DNA, ANA,

12.30 (ENT Division) Advice :

S: No epistaxis Keep up anterior tampon 2x24 hours
Planning for taking up tampon tomorrow

PARKIT S: gingival haemorrhages (+), epistaxis from the dextra - Obs. Bicytopenia + organomegaly Infusion D5 ½ NS 1200/50ml/hour
16/04/2019 nose, gum bleeding dd/ suspect hematology malignancy Per Oral:
05.00 O: general conditions: alert - Advice from DPJP: consult with - Paracetamol tab 500mg/4-6hour (t > 38oC)
Day : 3 HR : 108x/minute N : regular, adequate mouth surgery, clinical pathology - Captopril 12,5mg/8hour
RR : 24x/minute t : 36,7 oC and anesthesiologist - Allopurinol 300mg/12hour
SpO2 : 98%
PROGRAM:
Hematology 16/4/19 - Wait the result of blood cultures and urine cultures (14/3/19)
Hb: 11.9 - Wait the result of diff count and peripheral blood smear
Ht: 34.1 (14/3/19), dengue blot (14/3/19)
Leu: 5.700 - PRC transfusion (250ml; 250ml; 250ml)
Platelets: 252.000 - Suggestion from nutrition division: check lipid profile (fasting
Diff Count 16/4/19 12 hours)
E5/B0/Bt1/S59/L31/M3 - Consult to Dental Surgery division
LPB 2/100 leucocyte, metamyelocyte 1% - Consult to Clinical Pathology
Peripheral Blood Smear 16/4/19 - Consult to Anesthesiology
Erythrocyte: mild anisocytosis, mild poicilocytosis
Thrombocyte: normal count, normal shape
Leucocyte: normal count, activated lymphocyte (+),
eosinophilia, neutrophil hypergranulation (+)
Imunoserology 16/4/19
Anti DsDNA: 68.9
ANA: 19.6

06.10 S: patient was hungry

O: general conditions: alert nurse could not take blood sample
examination of ENT division

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06.30 (ENT Division) Advice :
S: Epistaxis (+) at 5 a.m Delay aff tampon

06.40 S: TRC, the patient was not alert, the extremities still - Cardiorespiratory failure
warm - Hypoglycemia - D40% bolus 1 fl
O: general conditions: sopor-koma - CPR + education to the family
HR : 158x/minutes
P : inadequate volume and pressure
RR : apneu SpO2 : 88 oC
Blood glucose: 20mg/dL

06.45 S: the patient was not alert

O: general conditions: soporocoma - Cardiorespiratory failure - CPR
HR : 162x/minutes P : not palpable - Suspect hypoglicemic shock - Education to the family
RR : apneu SpO2 : 88 oC
BT : not heard
Blood glucose: 111 mg/dL
Eyes: light reflex (-/-), pupil midriated (+/+)

06.50 S: the patient was not alert - Cardiorespiratory failure - CPR

O: general conditions: coma - Suspect Hypoglycemic shock - Adrenalin 1 amp (I)
HR : 160x/minutes P : not palpable
RR : apneu SpO2: 77%
Eyes: light reflex (-/-), midriasis (+/+)

06.55 S: the patient was not alert - Cardiorespiratory failure - CPR

O: general conditions: coma - Suspect Hypoglycemic shock - Adrenalin 1 amp (II)
HR : 148x/minutes P : not palpable
RR : apneu SpO2: 68%
Eyes: midriasis (+/+)

07.00 S: the patient was not alert - Cardiorespiratory failure - CPR

O: general conditions: coma - Adrenalin I amp (III)
HR : 100x/minutes N : not palpable - Advice from DPJP: consult to ERIA division
RR : apneu SpO2: 70%

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07.05 S: the patient was not alert - Cardiorespiratory failure - CPR
O: general conditions: coma - Adrenalin I amp (IV)
HR : 88x/minutes P : not palpable
RR : apneu SpO2: 68%

07.10 S: the patient was not alert - Cardiorespiratory failure - CPR

O: general conditions: coma
HR : 60x/minutes P : not palpable
RR : apneu SpO2: 40%

- CPR
07.15 S: the patient was not alert - Cardiorespiratory failure
O: general conditions: coma
HR : 18x/minutes P : not palpable
RR : apneu SpO2: -

- The patient was not response

07.20 S: maximal midriasis, no spontaneous breathing, CPR - Cardiorespiratory arrest - CPR already done for 20 minutes
was done and already given adrenaline 4 times. - The patient was called time of death
O:HR : 0 P : not palpable - Emotional support
RR : 0
SpO2 : not detected
Pupils: maximal midrates

07.20 S: the patient was not awaken - Cardiorespiratory arrest - The patient was declared death
O: HR : - P: - - Emotional support the family
RR : - SpO2: -
ECG : flat
Pupils: maximal midrates

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 SCHEME OF DEATH

A 13 years 9 months old boy with bicytopenia observation and organomegaly dd/ suspect of hematology malignancy dd/ALL,
AML, overweight, hypertension stage I, metabolic syndrome

Mielo-suppresion Hyperuricemia Dyslipidemic Hypertension

Anemia Trombocytopeni Suspect tumor Metabolic

a lisis syndrome syndrome
GNAPS

Gum
Epistaxis Hypoglicemia
bleeding

Sepsis

Shock

Cardiorespiratory failure CPR

Epinephrine
Response (-)

Cardiac arrest Emotional support keluarga

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Death