CLINICAL CONFRENCE

HEMATO ONKOLOGI DIVISION

(Death Case )
JUNE 11, 2021

Nurwahyuni/ Presenter
Gusti Rante Tiballa, Kharisma Andi Akhmad/ Madya Divisi
Maya Susanti, Try Kartika, Nurul Sylvana, Rosalia Sri wahyuni, Nadya
Abu Bakar/ Senior Divisi
 HISTORY TAKING
Chief Complain
Epistaxis and gum bleeding
History of Present Illness
A girl aged 5 years 4 months was admitted to the hospital referred from flamboyan clinic with
complaints of epistaxis and gum bleeding since 3 day prior to admission. There was bruises noticed
since 3 days before admission to the hospital. There was pallor noticed since 1 week before admission
to the hospital. There was lumps on the neck,axilla, and inguinal region that increased since 3 weeks
before being admitted to the hospital.
No fever. There was history of fever since 1 week ago. No Seizures. No cough, no shortness of breath.
No vomiting,
patient wanted to eat and drink
Urination: normal
Defecation: normal
 HISTORY TAKING
History of Illnes
No History of artralgia.
No history of cancer in family
No history of live in factory or field environment.
No history of got blood transfusion.
No history of treatment before.
 HISTORY TAKING
History of Past Illness
There was history of treated at Wahidin Hospital in March 2021 with a diagnosis of leukemia
and hyperleukocytosis for 1 day and returning home at family’s own request.
There was history of being treated in the PICU of Wahidin Hospital in April 2021 for 3 hours
with a diagnosis of post status epilepticus, anemia, leukocytosis, reactive thrombocytosis
then transferred to normal care for 3 days, performed Bone Marrow Puncture with normal
bone marrow results, recommended Bone marrow puncture 2 months later, control to the
hospital for tuberculosis tracking
No history of blackish defecation or reddish urination.
No history of malignancy in the family
No history of living in a plantation, mining or factory area
 PATIENT IDENTITY
( Female)
MR Number 931462
Date of Birth January 12th 2016
Admission Date May 25th, 2021

MEDICAL DIAGNOSIS
PATIENT PICTURE
 PHYSICAL EXAMINATION
Vital Sign Antropomethry
Consciousness: GCS 15 (E4 M6 V5) Body weight : 14 kg
Blood Pressure : 90 / 60 mmhg Height or Length : 102 cm
Heart Rate : 110 times/min Head Circumference : 49 cm (48-53cm)
Temperature : 36.5 °C Weight for Length : 14/16 X 100%=87,5% (malnourish)
Respiration Rate : 24 times/min Weight for Age : 14/19 X 100%= 73,6% underweight)
SpO2 : 99 % Length for Age : 104/111 X 100% = 93%(normal stature)
 PHYSICAL EXAMINATION
History of Vaccine
Vaccine 1 2 3 4 Mark
Hep B √ √ √ √
BCG √ - - -
DPT √ √ √ -
POLIO √ √ √ √
MR / CAMPAK √ - - -
OTHER -

History of Growth and Development

Observe the hand : Not remember Pointing the object : Not remember
Grabbing object : Not remember First tooth : Not remember
Prone position by self : Not remember
 PHYSICAL EXAMINATION
There was pale no Jaundice.There was lymphadenopathy
- 2 submental regions, size 3x2cm
- The right submandibular region 2 pieces each 1 piece measuring 2x1 cm and 1x1
cm- Left submandibular region 1 piece size 1x1cm
- Region colli dextra 2 pieces size 2x1 cm
- Regio colli sinistra 3 pieces, size 2x1 cm
- Posterior left suboccipital region 3 pieces, size 2x1cm
- Posterior dextra suboccipital region 2 pieces size 2x2 and 2x1 cm
- left axillary region 1 piece size 2x2cm
- Right inguinal region 1 piece 3x2 cm, 3 pieces 2x1cmLeft inguinal region 4
pieces, 2 pieces size 2x2 cm, 1 piece size 2x1cm, 1 piece size 1x1cm
 PHYSICAL EXAMINATION
Faring No hiperemis
Tonsil T1-T1 no hiperemis
There was piano chest
Pulmo
Vesicular breath sounds.
There was Ronchi, No wheezing
Cardiovascular
I / II heart sound, Regular rhythm
no murmur
Abdomen
Peristalsis is normal impression,
Palpable liver 8 cm below the
costal arc, 8 cm below the
xyphoid process, palpable spleen
: schuffner III
Spontaneous bleeding manifestations:
- Epistaxis and hematoma of the left
antebrachii region, right dorsum of the
manus, left femoral, and right cruris
TB Score
Contact 0
Tuberculin test not yet
Malnutrition 2
Fever 1
Cough 0
Lymph 1
Bone 0
Rontgen 1
Total 5 (without Mantoux test) (Mantoux
test: Positive)
 LABORATORY FINDING
June 6th 2021
MaY 25th MaY 27th 2021 MaY 30th 2021
Laboratory MaY 26th 2021 MaY 28th 2021 Normal Value
2021

Hb 5,7 9.1 7,4 9,8 9,6 7,4 12.0 – 16.0 gr/dL

WBC 226.100 147.000 83.300 40.700 79,700 26.200 4.0 – 10.0 x 103/μL

19.000 10.000
PLT 33.000 56.000 22.000 7.000 150 - 400 /mm3

MCV 85 87 87 87 88 88 80 -100 μm3

MCH 28 28 29 28 28 31 27 - 32 Pg
NEUT 2.14 86.9 3,2 3,1 2,4 4,6 52 – 75 %
LYMPH 33,9 8.0 59 63,7 55,5 83,0 20 – 40 %
MONO 63,4 4.9 36,9 31,7 41,1 9,7 2 – 8 103/μL
ANC 5.736 127.743 2.665,6 936,1 1.912,8
SGOT/SGPT 102/14
Uric Acid 8,0 19,4
Calcium 9,1
 June 6th 2021
Laboratory Normal

PT 15.0 10-14
INR 1,48 -

APTT 40,2 22-30

 Laboratory Finding
June 6th 2021
Urine June 2nd 2021 June 3th 2021 June 4 2021

Color Light Yellow Yellow Light yellow Yellow

PH 7.0 7,0 7,0 6,5

BJ <=1.005 1.005 <=1.005 1.015

Protein Negative Trace Negative +/30

Glucose Negative Negative +++/ 500 ++/250

Billirubin +/10 Negative Negative Negative
Urobilinogen Normal Normal Normal Normal
Keton Negative Negative Negative Negative
Nitrit Negative Negative Negative Negative
Blood Negative Negative Negative Negative
Leukocyte +/15 Negative Negative Negative

Epithelial Cells 16 12 0 19

Leukocyte Sedimen 3 4 2 3

Crystal Sedimen 0 0 2 2

Erytrocyte sedimen 1 2 0 1
 LABORATORY FINDING
Laboratory Bone Marrow Punction Mei 28th 2021
Impression: Acute Lymphoblastic Leukemia (ALL)-L1

Laboratory JUNE th
2021 Normal Value

NOT DETECTED cDNA-SARS-

NOT DETECTED
cDNA-SARS-CoV-2 CoV-2
cDNA-SARS-CoV-2
 RADIOLOGICAL FINDING
. Thorax (06/06/2021) Impression:

Pneumonia Bilateral

Tuberculosis with cavitas

Cardiomegaly
 Assesment
- Acute Lymphoblastic Leukemia (ALL)-L1
- Hyperleukocytosis
- Anemia
- Febrile Neutropenia
- Pulmonary tuberculosis
- Increased of Transaminase enzym
- Nutritional Marasmus
 Planning
- Oxygen 2 liters/minute via nasal cannula
- Fluid Hydration 1.5 maintenance requirements =Infusion of Nacl 0.9%:Dex 5% =
1:3/intravenous
- Watch for tissue anoxia
- PRC transfusion
- Platelet Transfusion
- Watch for manifestations of spontaneous bleeding
- Sodium bicarbonate /oral (if urine pH <6.5)
- Consult to respiratory division
- Consul for nutrition and metabolic disease division
 June 7 2021
th
05.00
S : There was decreased level of A : Desaturation
consciousness, increasing dyspneu
O:
General condition: GCS 10 E3M4V3
P : Oksigen 10 Via NRM
Blood pressure 100/60mmhg
Pulse: 86 beats per minute
Respiratory rate 60
Temperatur 39,7
SpO2 93% via nrm
 June7 2021
th
05.30
 S: There was decreased level of A : Desaturation
consciousness, increasing dyspneu
O:
General condition: GCS 9 E2M4V2
P : Oxygen via Jacson reese 10
lpm
Blood pressure 90/60mmhg
Consult to away management
Pulse: 144 beats per minute
Respiratory rate: 56 times per minute Consult PICU
Temperature: 37 Education to family
SpO2 78% via nrm
 June 7 2021 th
06.00
 S: there was gasp of breath
A : Desaturation
desaturation
O: P : Oxygen via Jacson reese 10 lpm
General condition: GCS 3 E1M1V1 Plan to ETT (family refuse)
Blood pressure 90/60mmhg
Pulse: 54 beats per minute
Respiratory rate: 48 times per minute
Temperature: 3
SpO2 68% via VTP Jackson reese
 06.15 am
• S: apneu , asystole
• A:
• Cardiac arrest
• O:
• Desaturation
• Bp not measurable
• Pulse not palpable • P:
• Respiratory rate apneu • Positive pressure ventilation
• Sp.02 60 % via non via Jackson reese
jacson reese • CPR
• Temperature 38,5 • Epinephrine 0,1mg/kg,
intravenous
• Crt > 2 seconds
The resuscitation failed and the
patient passed away
 CAUSE OF DEATH
TUMOR LYSIS SYNDROME DUE TO HYPERLEUKOSITOSIS DUE
TO ACUTE LYMPOBLASTIK LEUKEMIA L1 HIGH RISK

WORSENED BY :
•ACUTE KIDNEY INJURY STADIUM INJURY
•CIMMUNITY ACQUIRED PNEUMONIA
•LUNG TUBERCULOSIS ON TREATMENT 1ST MONTH
•HIPERURISEMIA
•ANEMIA
•TROMBOSITOPENIA