dr.

Fakhri

MORNING REPORT
Date : Tuesday 29/6/2021
Physician in charge
IA : dr. Fakhri, dr. satiti
IB : dr. Rara
IB HCU : dr. Alfan
II Consult : dr. Heru
II Incovit : dr. Sandi
II ER Incovit : dr. Tama
II UGD : dr. Ani, dr. Helsa
Chief on duty : dr. Fiqih
Consultant on duty : dr. Heri sutanto, Sp.PD, K-GH
Facilitator : Prof. Dr. dr. Achmad Rudjianto, Sp.PD, K-EMD
 Summary of Database
Mr. AB / 48.y.o/Ward 27 Bed 14
Autoanamnesa
Chief Complaint:
Bloated stomach
History of Present Illness:
The patient was admitted to the hospital from the HOM clinic for leukopharesis. Currently, the
patient complained bloated stomach since 1 month ago. He felt that his stomach was full and didn’t feel
well, and some times he had difficulties to do acticity because of his stomach. He also felt decreased of
appetite, but there is no nausea and vomiting
He was diagnosed with CML since 6 years ago, at first he felt that his body is weak and
intermittent fever, and there is decreased of body weight around 10 kgs 4 months and when he checked
complete blood count in puskesmas, known that his leucocyte count is high.
Now he said that routinely consumed Tasigna 2x400 mg since 2019.
 Summary of Database
Past Medical History:
He was hospitalize for a few times, because of he need leucopharesis and blood transfusion
Family History:
His Father had hypertension. None of his family had a history of malignancy, chronic disease,
such as DM. His grandfather and grandmother were passed away but he didn’t know what was the
cause.
Social History:
Patient is an unemployee, the daily activities mostly spent in his home, married, and has 2
children.
Review of System:
General: fatigue (+)
Skin: within normal limit
Head and neck: within normal limit
Respiratory: shortness of breath (-)
Gastrointestinal: abdomen felt hard
Extremities: within normal limit
 Physical Examination
General appearance looked moderately ill VAS 0/10
GCS 456 Compos Mentis, KS 80% BW 50 kg; BH 160 cm; BMI 19,5 kg/m2

BP 132/75 mmHg PR 90 bpm regular strong RR 20 tpm Tax 36,5 oC Sat O2 98%RA
Head Anemic Conjuctiva (+)

Neck JVP R+ 2 cmH20 30 degrees, enlargement lymph nodes (-)

Chest Symmetrical, retraction (-)

Lung Sonor | Sonor Vesicular| Vesicular Rhonkhi : - | - Wheezing : -|-

Sonor | Sonor Vesicular| Vesicular
-| - -|-
Sonor | Sonor Vesicular| Vesicular
-| - - |-
Cardio Ictus invisible, palpable at ICS V MCL (S)
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen Flat, soefl, Bowel Sound (+) normal

Liver/ liver span 10 cm, epigastrium tenderness (-)
Lien traubes space dullness, schuffner 4/8

Extremities Edema (+) , MMT 5 | 5 , looked pale (+)

5|5
 Laboratory Findings (29/06/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 168.910 4.700 – 11.300 /µL Ur/Cr

Hemoglobine 6.0 11,4 - 15,1 g/dl Albumin 3,5-5 g/dL

PCV 17.7% 38 - 42% OT/PT <24 / < 31 U/L

Thrombocyte 342.000 142.000 – 424.000 /µL SE Na 135-150; K 3,5-5,5; Cl

97-106 mmol/L
MCV 82.0 80-93 fl

calcium
MCH 28.0 27-31 pg

Eo/Bas/Neu/ 0.5/ 3.1/ 72.9/ 12.7/ 0-4/0-1/51-67/ Phospor

Limf/Mon 10.8 % 25-33/2-5
asam urat
swab antigen negatif
covid 19
Electrocardiography (29/06/2021)
 Electrocardiography (29/6/2021)
• Sinus rhythm, HR 86 bpm regular
• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : normal
• PR interval : 0.16”
• QRS complex : 0.08”
• Q wave : no pathological Q
• QT interval : 0.40”
• ST segment : isoelectric

Conclusion : Sinus Rhythm with HR 86 bpm

Chest X-Ray (29/06/2021)
 Chest X-Ray (24/03/2021)

• AP position, symmetric, enough KV, less inspiration

• Soft tissue was normal and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovascular pattern was Normal. No visible
infiltrate, cavity or nodules.
• Cor: site N, shape N, CTR seems enlarge =d because not
enough inspiration and PA position, cardiac waist (-), apex
embedded

Conclusion:
Normal CXR
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
1. CML - - Non Pharmacotherapy : S, VS, Sign of
Mr. AB / 48.y.o/Ward 27 Accelerated - High Calories high protein TLS,
Subjective Phase Diet 1800 kcal/day, fluid Leucostasis
- Fatigue intake 2 L/day, target UOP
100 cc/hour sign
- Diagnosed with CML
- Routinely consumed Pharmacotherapy P.Ed:
Tasigna 2x400mg - IVFD NS : Futrolit 3:1 Educate Patient
2000cc/24hr and the family
Objective - PO Tasigna 2x400 mg that patient
Abd : lien schuffner 4/8 - PO Allopurinol 1x300 mg condition was
- PO Nabic 3x500 mg progressively
Laboratory worsened
- Pro Leucopharesis
Hb 6.0 g/dL
Leucocyte : 168.910 Patient
Diff. Count : compliance for
: 0.5/ 3.1/ 72.9/ 12.7/ 10.8 medication
%
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
2. Hyperleucocyte - - Non Pharmacotherapy : UOP, CBC
Mr. AB / 48.y.o/Ward 27 dt No 1 - High Carbohydrate high post
Subjective protein Diet 2000 Leucopharesis
- Diagnosed with CML kcal/day
- Oral intake 2-3L/day, , Leucostasis
target UOP 100 cc/hours sign,
Urine Ph, Sign
Objective Pharmacotherapy of TLS
Abd : lien schuffner 4/8 - IVFD NS : Futrolit 3:1
2000cc/24hr P.Ed:
Laboratory - PO Nabic 3x500 mg Educate
- PO Allopurinol 1x300mg Patient and
Leucocyte : 168.910 - PO Nabic 3x500 mg the family
Diff. Count : - Pro Leucopharesis
about
: 0.5/ 3.1/ 72.9/ 12.7/ 10.8 leucostasis
% sign and
condition can
be worsened
over time

Patient
compliance for
medication
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Anemia 2.1 reticulo Non Pharmacotherapy : UOP, CBC
Mr. AB / 48.y.o/Ward 27 normochromic Related sit - High Carbohydrate high post
Subjective normocyter to CML count protein Diet 2000 tranfusion,
- Diagnosed with CML kcal/day
- Oral intake 2-3L/day, tranfusion
target UOP 100 cc/hours reaction

Objective Pharmacotherapy P.Ed:

H/N : conjunctiva anemis - IVFD NS : Futrolit 3:1 Educate
(+) 2000cc/24hr Patient and
Abd : lien schuffner 4/8 - Transfusion of PRC 2 the family
flasks/day with Hb >= 10 about
Laboratory g/dL ltranfusion
Hb 6.0 g/dL reaction
MCV/MCH: 82,0 fL/ 28,0
pg Patient
Diff. Count : compliance for
: 0.5/ 3.1/ 72.9/ 12.7/ 10.8 medication
%
 Problem Analysis

Clonal proliferation of hematopoietic

progenitor

CML Hyperleucositosis

Immunocomprimised condition

Bone marrow infiltration

Anemia
 Risk Factors Analysis

Problem Theory Patient

CML The only risk factors for chronic Age 48

myeloid leukemia (CML) are: male
Radiation exposure: Being exposed
to high-dose radiation (such as being
a survivor of an atomic bomb blast or
nuclear reactor accident) increases
the risk of getting CML
Age: The risk of getting CML goes up
with age
Gender: This disease is slightly more
common in males than females, but
it's not known why

American Cancer society

Key Message Pathophysiology
 Key Message Pathophysiology
CML
(Chronic Myeloid Leukimia)

PATHOPHISIOLOGY
Translocation ABL in
chromosome 9th with
gene BCR in
chromosome 22 🡪 BCR-
ABL Protein
Bcr/Abl fusion proteins
can transform
hematopoietic
progenitor cells in vitro.
Key Message Diagnosis
Key Message Diagnosis
 Management Analysis
Problem Theory Patient

CML The goal CML treatment is to achieve complete remission • PO Tasigna

Including haematological remission, cytogenetic remission, and even 2x400 mg
biomolecular remission • PO
To achieve hematological remission by Hydroxyurea
using myelosuppressive drugs : 2x500 mg
• PO Nabic
Hydroxyurea 3x500 mg
• First choice for hematologic remission induction in CML • PO
• Dose 500-3000 h/day to maintain leucocyte 20.000-30.000 Allopurinol
• If Leucocyte 20.000-150.000 🡪 50 mg/kgBW/day divided in 2 dose until 1x300 mg
leucocyte 20.000
• If >150.000 🡪 need leucopharesys then 20 mg/kgBW/day until leucocyte
5000-15.000
Busulfan
• Dose 4-8 mg/day p.o, can be increased to 12 mg.day.
• If WBC level too high, give allopurinol and proper hydration

Tyrosine Kinase Inhibitor

• Monoclonal antibody designed to inhibit tirosin kinase inhibitor
• Besides hematologic remission, this drug can give cytogenetic remission.
Allopurinol
• Allopurinol given as prophylaxis from hyperuricemia : 300 mg/day
 Key Message Management

The goals of treatment of chronic myelogenous leukemia

(CML) are :
• Hematologic remission (normal complete blood cell count
(CBC) and physical examination (ie, no organomegaly)
• Cytogenetic remission (normal chromosome returns with
0% Philadelphia chromosome–positive (Ph+) cells)
• Molecular remission (negative polymerase chain reaction
[PCR] result for the mutational BCR/ABL mRNA), which
represents an attempt for cure and prolongation of patient
survival
 Key Message Social

• Patient with CML must be educated for the planned

leucopharesis routinely and compliance of the drugs
and planning treatment
• Good emotional support from the family, health care
provider, and spiritual support must be given to the
patient
 Condition This Morning

GCS : 4-5-6
BP : 118/66 mmhg
HR : 84 bpm
RR : 20 tpm
SpO2: 98% RA