TIMELINE

June 12th 2017 July 19th 2017 July 20th 2017 July 26th 2017 July 27th 2017

Initial
Patient
examination Initial Last
admitted to Reporting
by observation observation
Hospital
candidate

1
 PATIENT RECORD
Candidate: dr. Sansan Suhelda

I. IDENTITY
1.1 IDENTITY OF PATIENT
Registration Number : 42.37.xx
Patient Name : JR
Date of Birth : January 14th, 2010 (7 years 6 months)
Place of birth : RSU
Gender : Male
Nationality : Indonesia
Address : Indonesia
Hospital admission date : June 12, 2017
Length of Care : 1 month 7 days
Check Date : July 19, 2017

1.2 IDENTITY OF PARENTS

FATHER MOTHER
Name : MR SD
Age : 46 years old 45 years old
Occupation : Farmer Farmer
Education : Primary school Primary school

II. ANAMNESIS
(Aloanamnesis performed on the parents of the patient, doctor and the
medical records on July 20, 2017 at 12:00 pm in the hemato-oncology
ward)

Chief complaint : Fever

Addition complaint : Pale, bone pain

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2.1 HISTORY OF PRESENT ILLNESS
One month before hospital admission, the patient has a fever felt on the
palpability, but the temperature is not measured. Fever was arised and
descended with the administration of medication. Fever usually disappears
after 2 days, but then reappears. Fever wasn’t accompanied by colds,
chills, vomiting, convulsions or bowel and urination disorders. Patients also
felt bone pain on the whole body. Swollen complaints on the joints and
previous trauma history were denied by the patient and families. Patients
went to a general practitioner and only given fever-lowering drugs.
Patients appear pale. Pale was realized by the parents initially on the face,
pale also seen on the soles of the feet and hands. Pale with tiredness,
especially when playing or running. Eating out of the ordinary such as
eating soil, paper, and others was denied. Patients do not appear yellow,
both on the eyes and facial skin and limbs.
Appetite were good. Urinate last approximately 1 hour before
admission to hospital, enough volume, clear yellow color. Defecate was
normal as usual with once daily frequency, soft, yellow.
When used as a long case, the patient has no fever, does not look
pale. Complaints of bone pain was said to have diminished. Appetite was
good. Urinate and defecate were normal. Patient was undergoing
induction phase chemotherapy with protocol ALL Indonesia 2013 relapse
week 4.

2.2 Past medical history

 The patient has been diagnosed with LLA by 2014 and has
undergone chemotherapy completely.
 Patients often experience cough and colds, frequency ± 1-2 times
each month.
 History of diarrhea ever experienced with frequency + 2 times in
the past year.

3
  Allergy history of food and drugs is denied

2.3 Family disease history

No other family member suffers from a malignant disease of blood, nor
any other disease that has the same symptoms as the patient.

2.4 Family health history

 History of contact with exposure to secondhand smoke is denied

 Allergy to food/ drugs history is denied

THE FAMILY TREE

4
FAMILY MEMBER
No Name Relationship Sex Age Description
1. MR Father M 46 years old Healthy
2. SD Mother F 45 years old Healthy
3. NR Brother M 22 years old Healthy
4. AR Brother M 12 years old Healthy
5. PR Brother M 10 years old Healthy
6. JR Brother M 7 years 6 Patient
months old

2.5 SOCIAL HISTORY OF PATIENT

a. History of pregnancy
The patient was a fourth child in his family. The mother of the patient
performed an antenatal exam at the Primary health care 8 times. Mother
patient immunize Tetanus Toxoid (TT) 2 times. During pregnancy, the
mother admitted healthy, never taking drugs, alcohol or smoking. Mothers
only take vitamins from doctors during pregnancy. History exposed to
radiation (radiological examination), pesticides, paint and gasoline during
pregnancy was denied.
b. History of Labor
Patient was born full term, spontaneously, in a Primary Health Care
assisted by midwife. Birth weight was 3000 grams, birth length 50 cm. He
immediately cried after birth.
c. Post Birth History
Babies never look yellow or bluish. The baby can suck well. After birth, the
patient treated to join the mother and declared healthy by the doctor.
Patient have never been hospitalized after birth until now.
d. History of Feeding
The patient was given breastmilk since born until three months old, he
continued given formula milk until 12 months old. Milk porride was given at
three months old, then changed to strained porridge on eight months old.

5
He ate soft rice until 12 months old then continued with home meals. He
ate home meals start at age 3 years old until now with frequency three
times a day, one plate consists of rice with fish or chicken, or eggs and
vegetables.
e. History of Growth
Growth
Child has been examined for growth and development only until the age of
1 month at Primary Health Care and at that time it was said within normal
growth. After the age of 1 month, parents have never made a
measurement of either body weight or height. According to the mother, the
growth and development of the patient before the illness looks the same
as his peers.

Development
First time flipped : 4 months
First time to roll over : 5 months
First time to sit : 6 months
First time to crawl : 8 months
First time to stand : 9 months
First time to walk : 12 months
First time to laugh : 3 months
First time chattering : 5 months
First time to call mama : 12 months
First time to call papa : 12 months
First time to drink with cup : 14 months
First time using spoons and forks : 16 months
First time to jump : 20 months
First time to run : 17 months
First time able to kick the ball : 18 months
First time to wear clothes : 2 years
First time to brush his teeth : 3 years

6
First time to dressed without help : 4 years
First time drawing people: 5 years

f. Immunization History
Patients received a BCG vaccination (scarring +) in the right deltoid, polio
immunization 3x 3x Diphteria Pertusis Tetanus (DPT), Hepatitis B 3x, 1x
measles

g. History Of Basic Needs

Physic-biomedic :
Patients got breast milk from birth until age 3 months. PASI was given
when the patient is aged 3 months to 12 months. From the age of 3
months to 6 months, the patient was given milk porridge. The filtering
slurry begins at 8 months to 10 months. Delicate slurry was given when
patients aged 10 months to 12 months. Rice flabby at the age of 12
months to 18 months. Since the age of 18 months until now, get rice and
side dishes. In a day, the patient eats 3 times a day, each meal as much
as 1 full plate, with the type of household food in the form of rice, fish,
eggs, vegetables, and fruits.
If the patient was sick, parents bring medical treatment to primary
health care. Patients get suits that are worthy of use, family homes, good
self-hygiene, adequate environmental sanitation, sports and recreational
enough.

Emotional needs :
Compassion was obtained from both parents and family. The patient's
parents receive the condition of the patient's illness. Patients get enough
attention and affection from parents and family.

7
Mental stimulation :
Patient loves to play with other kids of the same age. Patients went to first
grade elementary school. Patients have many friends and easy to get
along with new friends.

SOCIAL ECONOMIC CONDITION AND ENVIRONMENT

Social Economic :
The patient’s father and mother worked as a farmer. Medical treatment
cost is covered by national insurance (BPJS).
Environment :
The patient lives with his parents and siblings, a house with a tin roof,
concrete walls, cement floors. The house consists of 2 rooms, occupied by
6 people, 3 adults and 3 children. Bathroom is located outside the house.
The source of water comes from PAM (State Water Company) and the
source of lighting comes from PLN (State Electricity Company). Handling
garbage by way of disposal. The patient's living environment is located in
a suburban area that is not densely populated. The patient's home is away
from the highway, not near a cell phone transmitter tower or an
electromagnetic high voltage source. Parents of smokers.

PATIENT’S HOSPITAL ADMISSION SUMMARY

Prior to candidate’s initial observation (12th June 2017- 19th July
2017)
Patients admitted to the hospital on June 12, 2017. When treated, patients
experience fever, looks pale and bone pain. On physical examination
obtained weight and height, 19 kg and 119 cm. Based on the CDC 2000
curve of boys aged 2 - 20 years weight gain according to height 86% with
less nutritional impression. General state of illness and conscious
awareness of compos mentis. Vital signs obtained 100/70 mmHg blood
pressure, pulse 100 times per minute (regular, enough content),
respiratory frequency 28 times / minute, and body temperature 36.80C. On

8
examination of head and neck conjunctiva anemic obtained. Chest
examination of the heart and lungs within normal limits. Abdominal
examination appears slightly convex, weakened with normal bowel sounds,
gained enlargement of the liver 4-4 cm under the costal arcus, sharp
edges, flat surface, consistency chewy and spleen is not palpable. The
limbs look pale, not cyanosis, felt warm with capillary refill time (CRT) <2
seconds.
Laboratory results at the time of admission of the hospital on June
12, 2017 obtained hemoglobin 7.9 g / dl, hematocrit 23.1%, leukocyte
10.500 / L, erythrocytes 3.17 x 106 / L, platelets 125 x 103 / L, MCH
24,9 pg, MCHC 34,2 g / dl, MCV 72,9 fL, blood chloride 89,0 mEq / L,
blood potassium 4,00 mEq / L, blood sodium 118 mEq / L, prothrombin
time 11,5 "(Control 12.0"), Activated Partial Thromboplastin Time 22.5
"(control 25-35"), INR 1.03 "(control 1.05"). In peripheral blood smear
examination, the impression of peripheral blood showed normocytic
normocytic erythrocyte erythrocytes, anisocytosis (+), poikilocytosis and
leucocytes normal number, with differential percentage: neutrophil 27%,
lymphocyte 29% monocyte 6%, 0% eosinophil, basophil 0% Suspicion of
blast cells, LLA impression, suggestions made Bone Marrow Puncture
(BMP) and immunophenotyping. At that time the patient was given a
packed red cell transfusion (PRC) as needed. Nutritional support in the
form of rice diet with side dish based on Recommended Daily Allowance
(RDA).
The results of examination of bone marrow features on June 15,
2017 showed the predominance of lymphoblast with L1 lymphoblast
morphology. The results of immunophenotyping showed gating in the blast
area looked positive with HLA-DR, CD19, CD10, CD20. B-Lineage
impression. Patient was diagnosed as acute lymphoblastic leukemia B-
Lineage relapse.
Patients planned to start chemotherapy with previous
complementary investigations before chemotherapy is given.

9
Echocardiography examination results obtained within normal, there is no
contraindication for the provision of cytostatic drugs. Chest X-ray
examination within normal limits. Consultation to the tooth and mouth
results in normal limits. ENT Consul (ear nose throat) obtained a normal
impression. Eye consul results obtained normal impression. Patients have
also been examined tuberculin test, obtained 0 mm results.
Laboratory test results on 16 June 2017 obtained hemoglobin 8.6 g
/ dl, hematocrit 27.1%, leukocyte 7996 / L, erythrocyte 3,51 x 106 / L,
platelet 62 x 103 / L, SGOT 36 U / L, SGPT 25 U / L, blood chloride
95,7mEq / L, blood potassium 4,04mEq / L, blood sodium 136mEq / L,
calcium 8.73mg / dl, magnesium 1,89mg / dl, phosphorus 4,7mg / dl , Urea
8mg / dl, creatinine 0.2mg / dl. Supportive nutrition in the form of rice diet
with side dish based on RDA still given.
Laboratory results on June 19, 2017 obtained hemoglobin 8.4 g / dl,
hematocrit 26.2%, leukocyte 10.080 / L, erythrocytes 3.38 x 106 / L,
platelets 82 x 103 / L. Supportive nutrition in the form of rice diet with side
dish based on RDA still given.
Results of cerebrospinal fluid analysis on June 20, 2017 obtained
cloudy liquid, leukocyte 105 / L, glucose 28 mg / dl, protein 40 mg / dl,
Nonne and Pandy (+), erythrocyte 0-2 / LPB, PMN 10%, MN 90 %.
Patients were diagnosed as acute lymphoblastic leukemia B-Lineage
combined relapse and central nervous system leukemia.
Patients initiated induction phase chemotherapy with oral
dexamethasone on 20 June 2017 based on the Indonesia acute
lymphoblastic leukemia protocol 2013 relapse with modification. During the
treatment of fever, pallor, and bone pain reduced.
Laboratory results on 26 June 2017 were obtained hemoglobin 7.3
g / dl, hematocrit 23%, leukocyte 4275 / L, erythrocytes 2.96 x 106 / L,
platelets 99 x 103 / L, SGOT 15 U / L, SGPT 19 U / L, 104 mEq / L blood
chloride, 3.4 mEq / L potassium blood, 135 mEq / L blood sodium. Patients

10
administered transfusion of PRC as needed and chemotherapy of
induction phase by intrathecal methotrexate and vincristine.
Laboratory results on July 3, 2017 were found hemoglobin 10.6 g /
dl, hematocrit 32.7%, leukocyte 4258 / L, erythrocytes 4.15 x 106 / L,
platelets 70 x 103 / L, Absolute Neutrophil Count 1362 , SGOT 28 U / L,
SGPT 52 U / L, blood chloride 99.6 mEq / L, blood potassium 3.58 mEq / L,
blood sodium 137 mEq / L, calcium 8.94 mg / dl. Supportive nutrition in the
form of rice diet with side dishes based on the RDA is still given and
chemotherapy continued according to the protocol with oral
dexamethasone.
On July 5, 2017, the patient performed a laboratory examination
with the results obtained hemoglobin 9.1 g / dl, hematocrit 28.2%,
leukocytes 4.315 / L, erythrocytes 3.60 x 106 / L, platelets 83.000 / L,
Absolute Neutrophils Count 2114. Supportive nutrition in the form of a diet
of rice with side dishes based on the RDA is still given and chemotherapy
continued according to the protocol by intrathecal methotrexate, vincristine
and oral dexamethasone.
Laboratory results on 10 July 2017 obtained hemoglobin 8.6 g / dl, 27%
hematocrit, leukocyte 6779 / L, erythrocytes 3,36 x 106 / L, platelets 116
x 103 / L, Absolute Neutrophil Count 4135, SGOT 16 U / L, SGPT 24 U /
L, blood chloride 98.6 mEq / L, blood potassium 4.43 mEq / L, blood
sodium 138 mEq / L, calcium 8.90 mg / dl, ureum 26 mg / Creatinine 0.2
mg / dl. Patients in the management with supportive nutrition support in
the form of rice diet with side dishes based on RDA and chemotherapy
continued according to the protocol with oral dexamethasone.
Laboratory results on July 17, 2017 obtained hemoglobin 7.3 g / dl,
hematocrit 21.1%, leukocyte 4530 / L, erythrocytes 2.73 x 106 / L,
platelets 184 x 103 / L, Absolute Neutrophil Count 1.721 , SGOT 19 U / L,
SGPT 20 U / L, blood chloride 102,7 mEq / L, blood potassium 3,6 mEq / L,
blood sodium 138 mEq / L, calcium 8,23 mg / dl, ureum 23 mg / Dl,

11
 creatinine 0.4 mg / dl. Patients administered transfusion of PRC as needed
and chemotherapy should continue according to the protocol.

Examination 12/6/2017 16/6/2017 19/6/2017 26/6/2017

Hb (g/dl) 7,9 8,6 8,4 7,3
Ery (x106/L) 3,17 3,51 3,38 2,96
Ht (%) 23,1 27,1 26,2 23,0
MCV (fL) 72,9 77,2 77,4 77,7
MCH (g/dl) 24,9 24,5 25,0 24,7
MCHC (pg) 34,2 31,7 32,2 31,8
Leukocyte (/L) 10.500 7996 10.080 4275
Platelet (/L) 125.000 62.000 82.000 99.000
Diff. count (%) - 5/4/0/27/47/17 - -
Blast (%) - - - -
ANC (cell/mm3 ) - 2158 - -
PT (sec) 11,5 - - -
APTT (sec) 22,5 - - -
INR (sec) 1,03 - - -

Kimia Klinik
AST (U/L) - 36 - 15
ALT (U/L) - 25 - 19
Urea (mg/dl) - 8 - 31
Creatinine - 0,2 - 0,3
(mg/dl) -
Chloride 89,0 95.7 - 104
(mEq/L) -
Potassium 4,00 4,04 - 3,40
(mEq/L) -
Sodium (mEq/L) 118 136 - 135
Calcium (mg/dl) - 8,73 -
Phosphor - 4,7 - -
(mg/dl) - -
Magnesium 1,89
(mg/dl) -
Uric acid (mg/dl) -

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Examination 3/7/2017 5/7/2017 10/7/2017 17/7/2017
Hb (g/dl) 10,6 9,1 8,6 7,3
Ery (x106/L) 4,15 3,60 3,36 2,73
Ht (%) 32,7 28,2 27,0 21,1
Leukocyte (/L) 4258 4315 6779 4530
Platelet (/L) 70.000 83.000 116.000 184.000
MCV (fL) 78,8 78,4 80,2 77,3
MCH (g/dl) 25,6 25,4 25,6 26,7
MCHC (pg) 32,4 32,4 31,9 34,6
Diff count (%) 4/1/8/24/53/10 3/1/2/47/44/3 0/1/15/46/33 7/0/1/37/50/5
Blast (%) - - - -
ANC (sel/mm3 ) 1362 2114 4135 1721

Kimia Klinik
AST (U/L) 28 - 16 19
ALT (U/L) 52 - 24 20
Urea (mg/dl) 14 - 26 23
Creatinine (mg/dl) 0,3 - 0,2 0,4
Chloride (mEq/L) 99,6 - 98,6 102,7
Potassium 3,58 - 4,43 3,60
(mEq/L) -
Sodium (mEq/L) 137 - 138 138
Calcium (mg/dl) 8,94 - 8,90 8,23
Phosphor 5.0 - 4,5 4,3
(mg/dl)
Magnesium 3,56 2,05 1,93
(mg/dl)

Differential Erythrocyte
count Normocochal Normocytes, Anisositosis (+),Poikilositosis (+)
(12/6/2017) Leucocyte
The impression of normal upper (high-normal)
Differential : Eosinophil 3%, Basophil 0%, Metamyelocyte 6%,
Neutrophil stem 15%, Neutrophil segment 20%, Lymphocyte 29%,
Monocyte 27%. Many atypical lymphocytes, suspicion of blast cells.
Platelet
The impression amount is less. Morphology within normal limits
Impression: Suspect Acute Lymhoblastic Leukemia (ALL) relapse
ddx AML

Suggestion: BMP, leukemia phenotyping

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Bone Marrow Found blast cells (21%). Morphology matches lymphoblasts.
features Appropriate ALL-L1
(15/6/2017)

Leukemia Gating on the Blast area looks positive with HLA-DR, CD34, CD19,
Phenotyping CD10, CD20. B-Lineage impression
(15/6/2017)

LCS analysis Cloudy liquid, leukocyte 105 / L, glucose 28 mg / dl, Nonne and
(20/6/2017) Pandy (+), erythrocytes 0-2 / LPB, protein 40 mg / dl, PMN 10%, MN
90%

Head CT scan showed no impression of radiological abnormalities

(20/6/2017)

.
III. DATA AND CONDITIONS OF THE PATIENT
The examination was performed in the hemato-oncology ward on July 19,
2017 at 12.00 WITA
Complaints : Fever (-),pale (-),nose bleeding and gum (-), good
oral intake, urinate (+), defecate (+)
General condition : looked sick, Compos mentis
Anthropometric Status
Weight : 20.5 kg
Height : 119 cm
BSA : 0.81 m2

Nutrition status (CDC 2000 chart for boy aged 2-20 years)
Weight/Height = 93%, (Good nutrition)
Vital sign : blood pressure 100/70 mmHg, pulse 88 bpm
(regular,full pulse), respiratory rate 28 times per
minutes (regular) and body temperature 36,70C (axila).

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Skin : Brown color (-), effluorescence (-), scarring (-),
pigmentation (-), BCG scar (+) on the upper arm, edema (-),
sufficient subcutaneous fat, wrinkled skin (-), Jaundice (-)

Head and Neck

Head : mesocephal, black hair not easily removed, alopecia (-),
hematoma (-)
Eyes : palpebra edema (-), conjungtiva anemic (-),
sclera icteric (-), corneal reflex +/+, round pupil, isocor,
diameter 3 mm, light reflex (+), strabismus -/-, normal
movement, nistagmus -/-
Nose : no secretes, flare (-)
Ear : no secretes (-)
Mouth : cyanosis (-), wet mucosa, atrophy of tongue papil (-)
Throat : tonsils T1/T1, tonsils and pharynx not hyperemia.
Neck : trachea in the middle, lymph node not enlarge.
Chest : symetrical shape, no retraction

Heart
Inspection : ictus cordis unseen
Palpation : ictus cordis palpable in left midclavicule line, 5th
intercostal space, no thrill
Percussion : left heart margin at the left midclavicularis line,
right heart margin at the right parasternal line,
upper heart margin at II-III intercostal space
Auscultation : heart rate frequency 80 bpm, regular, murmur (-)

Lung
Inspection : symmetrical respiratory movement
Palpation : symmetrical stem fremitus
Percussion : sonor at both lung

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Auscultation : normal, vesicular breath sounds, no rales, no
wheezing

Abdomen
Inspection : flat, no venectation
Palpation : palpable liver 2 cm below costal arcus and 2 cm
below xyphoideus process, sharp edge, flat surface,
supple consistency, tenderness (-), lien not palpable
Percussion : tympanic, ascites (-)
Auscultation : normal bowel sound

Spine : no deformity
Genitals : male, palpable bilateral testicles inside the scrotum,
large normal, no palpable mass.
Extremities : warm, no cyanotic, capillary refill time less than 2
seconds, normal muscle tone, spastic (-)
Muscle : good muscle tone

Neurology Status
Reflex : Normal physiology reflex, patology reflex (-)
Stiff neck : negative
Sensoric : normal limit
Motoric : strength of four body limbs was normal

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

16
  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 tongue deviation

IV. RESUME
Patients admitted to the hospital on June 12, 2017. When treated, patients
experience fever, looks pale and bone pain. On physical examination
obtained weight and height, 19 kg and 119 cm. Based on the CDC 2000
curve of boys aged 2 - 20 years weight gain according to height 86% with
less nutritional impression. General state of illness and conscious
awareness of compos mentis. Vital signs obtained 100/70 mmHg blood
pressure, pulse 100 times per minute (regular, enough content),
respiratory frequency 28 times / minute, and body temperature 36.80C. On
examination of head and neck conjunctiva anemic obtained. Chest
examination of the heart and lungs within normal limits. Abdominal
examination appears slightly convex, weakened with normal bowel sounds,
gained enlargement of the liver 4-4 cm under the costal arcus, sharp
edges, flat surface, consistency chewy and spleen is not palpable. The
limbs look pale, not cyanosis, felt warm with capillary refill time (CRT) <2
seconds.
Laboratory results at the time of admission of the hospital on June
12, 2017 obtained hemoglobin 7.9 g / dl, hematocrit 23.1%, leukocyte
10.500 / L, erythrocytes 3.17 x 106 / L, platelets 125 x 103 / L, MCH
24,9 pg, MCHC 34,2 g / dl, MCV 72,9 fL, blood chloride 89,0 mEq / L,
blood potassium 4,00 mEq / L, blood sodium 118 mEq / L, prothrombin
time 11,5 "(Control 12.0"), Activated Partial Thromboplastin Time 22.5
"(control 25-35"), INR 1.03 "(control 1.05"). In peripheral blood smear
examination, the impression of peripheral blood showed normocytic

17
normocytic erythrocyte erythrocytes, anisocytosis (+), poikilocytosis and
leucocytes normal number, with differential percentage: neutrophil 27%,
lymphocyte 29% monocyte 6%, 0% eosinophil, basophil 0% Suspicion of
blast cells, LLA impression, suggestions made Bone Marrow Puncture
(BMP) and immunophenotyping. At that time the patient was given a
packed red cell transfusion (PRC) as needed. Nutritional support in the
form of rice diet with side dish based on Recommended Daily Allowance
(RDA).
The results of examination of bone marrow features on June 15,
2017 showed the predominance of lymphoblast with L1 lymphoblast
morphology. The results of immunophenotyping showed gating in the blast
area looked positive with HLA-DR, CD19, CD10, CD20. B-Lineage
impression. Patient was diagnosed as acute lymphoblastic leukemia B-
Lineage relapse.
Patients planned to start chemotherapy with previous
complementary investigations before chemotherapy is given.
Echocardiography examination results obtained within normal, there is no
contraindication for the provision of cytostatic drugs. Chest X-ray
examination within normal limits. Consultation to the tooth and mouth
results in normal limits. ENT Consul (ear nose throat) obtained a normal
impression. Eye consul results obtained normal impression. Patients have
also been examined tuberculin test, obtained 0 mm results.
Laboratory test results on 16 June 2017 obtained hemoglobin 8.6 g
/ dl, hematocrit 27.1%, leukocyte 7996 / L, erythrocyte 3,51 x 106 / L,
platelet 62 x 103 / L, AST 36 U / L, ALT 25 U / L, blood chloride 95,7mEq
/ L, blood potassium 4,04mEq / L, blood sodium 136mEq / L, calcium
8.73mg / dl, magnesium 1,89mg / dl, phosphorus 4,7mg / dl , Urea 8mg /
dl, creatinine 0.2mg / dl. Supportive nutrition in the form of rice diet with
side dish based on RDA still given.
Laboratory results on June 19, 2017 obtained hemoglobin 8.4 g / dl,
hematocrit 26.2%, leukocyte 10.080 / L, erythrocytes 3.38 x 106 / L,

18
platelets 82 x 103 / L. Supportive nutrition in the form of rice diet with side
dish based on RDA still given.
Results of cerebrospinal fluid analysis on June 20, 2017 obtained
cloudy liquid, leukocyte 105 / L, glucose 28 mg / dl, protein 40 mg / dl,
Nonne and Pandy (+), erythrocyte 0-2 / LPB, PMN 10%, MN 90 %. Then
performed a CT scan of the head without and with contrast with the axial
slices showed no impression of radiological abnormalities. Patients were
diagnosed as acute lymphoblastic leukemia B-Lineage combined relapse
and central nervous system leukemia.
Patients initiated induction phase chemotherapy with oral
dexamethasone on 20 June 2017 based on the Indonesia acute
lymphoblastic leukemia protocol 2013 relapse with modification. During the
treatment of fever, pallor, and bone pain reduced.
Laboratory results on 26 June 2017 were obtained hemoglobin 7.3
g / dl, hematocrit 23%, leukocyte 4275 / L, erythrocytes 2.96 x 106 / L,
platelets 99 x 103 / L, AST 15 U / L, ALT 19 U / L, 104 mEq / L blood
chloride, 3.4 mEq / L potassium blood, 135 mEq / L blood sodium. Patients
administered transfusion of PRC as needed and chemotherapy of
induction phase by intrathecal methotrexate and vincristine.
Laboratory results on July 3, 2017 were found hemoglobin 10.6 g /
dl, hematocrit 32.7%, leukocyte 4258 / L, erythrocytes 4.15 x 106 / L,
platelets 70 x 103 / L, Absolute Neutrophil Count 1362 , SGOT 28 U / L,
SGPT 52 U / L, blood chloride 99.6 mEq / L, blood potassium 3.58 mEq / L,
blood sodium 137 mEq / L, calcium 8.94 mg / dl. Supportive nutrition in the
form of rice diet with side dishes based on the RDA is still given and
chemotherapy continued according to the protocol with oral
dexamethasone.
On July 5, 2017, the patient performed a laboratory examination
with the results obtained hemoglobin 9.1 g / dl, hematocrit 28.2%,
leukocytes 4.315 / L, erythrocytes 3.60 x 106 / L, platelets 83.000 / L,

19
Absolute Neutrophils Count 2114. Supportive nutrition in the form of a diet
of rice with side dishes based on the RDA is still given and chemotherapy
continued according to the protocol by intrathecal methotrexate, vincristine
and oral dexamethasone.
Laboratory results on 10 July 2017 obtained hemoglobin 8.6 g / dl, 27%
hematocrit, leukocyte 6779 / L, erythrocytes 3,36 x 106 / L, platelets 116
x 103 / L, Absolute Neutrophil Count 4135, AST 16 U / L, ALT 24 U/ L,
blood chloride 98.6 mEq / L, blood potassium 4.43 mEq / L, blood sodium
138 mEq / L, calcium 8.90 mg / dl, urea 26 mg / Creatinine 0.2 mg / dl.
Patients in the management with supportive nutrition support in the form of
rice diet with side dishes based on RDA and chemotherapy continued
according to the protocol with oral dexamethasone.
Laboratory results on July 17, 2017 obtained hemoglobin 7.3 g / dl,
hematocrit 21.1%, leukocyte 4530 / L, erythrocytes 2.73 x 106 / L,
platelets 184 x 103 / L, Absolute Neutrophil Count 1.721 , AST 19 U / L,
ALT 20 U / L, blood chloride 102,7 mEq / L, blood potassium 3,6 mEq / L,
blood sodium 138 mEq / L, calcium 8,23 mg / dl, urea 23 mg / Dl,
creatinine 0.4 mg / dl. Patients administered transfusion of PRC as needed
and chemotherapy should continue according to the protocol.

V. DIAGNOSIS
Acute lymphoblastic leukemia B-Lineage relapse (C91.02)
Leukemia of the central nervous system (C91.00)

VI. PROBLEMS
- Prognosis problems
- Prognosis of 7-year-old boy 6 months with acute lymphoblastic
leukemia B-Lineage relapse and central nervous system leukemia

20
VII. MANAGEMENT PLAN
1. Emergency management
- The current condition of the patient is stable hemodynamic
status so that no emergency management is required
2. Work plan for management
- Chemotherapy according to protocol LLA Indonesia 2013 relapse
with modification
- Complete blood examination, urine and feces samples
3. Pediatric Nutrition Care
A. Assesment of nutritional status
Male, 7 years 6 months old
Body Weight : 20,5 kg
Body Height : 119 cm
Nutrition status : well-nourished ( according to CDC 2000 chart
age 2 – 20 years boys)
B. Nutritional needs ( based on RDA)
Calories = 70 kcal/kgBW = 1540 kcal/day
Protein = 1 g/ kgBW = 22 g/day
Fat = 30 % x 1540 kcal = 21 g/day
Fluid = 70 – 85 ml/KgBW = 1540 – 1870 ml/day
C. Nutritional route
Nutrition is given orally
D. Type of food : polymeric
Given in the form:
- Food 3x 1 portion (@ 500 kcal, 7 g protein, 10 g fat)
In the form :
• Rice ¾ cup, side dishes (medium fish 1 medium “tempe”),
vegetables (beans 50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
E. Monitoring and evaluation :
Tolerance, adverse reactions and weight changes

21
4. Work plan for counseling

• Diseases, therapies, side effects during chemotherapy and after

chemotherapy and prognosis

• Immunization plan

5. Work plan for monitoring

- Monitoring the general state, vital signs

- Monitoring body weight per day
- Monitor daily nutritional, fluid, and caloric intake
- Monitoring of therapy, evaluation of treatment response,
therapeutic side effects such as daily gastrointestinal effects
and long-term monitoring of drug side effects such as hepatitis,
optic neuritis, peripheral neuritis.
- Monitor growth and development
- Hygiene monitoring for parents / caregivers, nurses, medical
personnel
6. Educational plan
- Describes the illnesses : causes, treatment, prognosis,
complications and treatment plans
- Explain how to feed according to the fulfillment of nutrition and
disease.
- Educate the impact on the child's social economic life because
of long-term treatment.
- Education to maintain the home environment.
- Education to maintain personal hygiene and avoid the
environment that can cause infection.

22
VIII. FOLLOW UP
20th July 2017 (1st observation day, 38th treatment day)
S Fever (-), bone pain (-), pallor (-), nausea (-), vomiting (-), good intake
O General condition : looked sick, compos mentis
Blood pressure : 100/70 mmHg Respiratory rate : 28 x/min
Pulse : 100 x/min, regular Temperature : 36,5oC (axilla)
Weight : 20,5 kg Height : 119 cm
BSA : 0,81
Head : normocephal
Face : symmetrical, not dysmorphic
Eyes : conjunctival anemic, sclera not jaundice
Neck : KGB enlargement (-)
Chest : no chest wall retraction
Abdomen : flat, bowel sound (+) normal, liver palpable 1-1 cm
below arcus costa, spleen not palpable
Extremities : warm, no cyanotic, capillary refill time less than 2 second
A Acute Lymphoblastic Leukemia B-Lineage relapse, induction phase
(C91.02) + Leukemia of the central nervous system (C91.00)
P Laboratory :
Urinalysis :
• Clear yellow color
• Erythrocyte : 0 - 1 / LPB
• Leukocyte : 0 - 1 / LPB
• Bacteria : (-)
• Nitrite : (-)
• Protein : (-)
• Glucose : (-)
Stool test :
• Color / concentration : brown / flabby
• Erythrocyte : 0 - 1 / LPB

23
 • Leukocyte : 0 - 1 / LPB
• Egg / worm larvae : (-)
• Bacteria : (-)
• Yeast : (-)
Therapeutic :
- Dexamethasone 4 – 4 – 2
- L- asparginase (II) in NaCl 0,9% 500 ml
Nutritional care :
Solid food and side dishes 3 x 1 portion (@ 500kkal,7g protein,10g fat)
consists of :
• Rice ¾ cup, side dish (chicken meat 1 medium cut + “tempe” 1
medium cut), vegetables (50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
Water 1,500 ml / day

21th July 2017 (2nd observation day, 39th treatment day)

S Fever (-), bone pain (-), pallor (-), nausea (-), vomiting (-), good intake
O General condition : looked sick, compos mentis
Blood pressure : 90/70 mmHg Respiratory rate : 28 x/min
Pulse : 92 x/min, regular Temperature : 36,5oC (axilla)
Head : normocephal
Face : symmetrical, not dysmorphic
Eyes : conjunctival anemic, sclera not jaundice
Neck : KGB enlargement (-)
Chest : no chest wall retraction
Abdomen : flat, bowel sound (+) normal, liver palpable 1-1 cm
below arcus costa, spleen not palpable
Extremities : warm, no cyanotic, capillary refill time less than 2 second

24
A Acute Lymphoblastic Leukemia B-Lineage relapse, induction phase
(C91.02) + Leukemia of the central nervous system (C91.00)
P Therapeutic :
- Dexamethasone 4 – 4 – 2
Nutritional care :
Solid food and side dishes 3 x 1 portion (@ 500kkal,7g protein,10g fat)
consists of :
• Rice ¾ cup, side dish (fish 1 medium cut + “tahu” 1 medium cut),
vegetables (50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
Water 1,500 ml / day

22nd July 2017 (3rd observation day, 40th treatment day)

S Fever (-), bone pain (-), pallor (-), nausea (-), vomiting (-), good intake
O General condition : looked sick, compos mentis
Blood pressure : 100/70 mmHg Respiratory rate : 24 x/min
Pulse : 88 x/min, regular Temperature : 36,5oC(axilla)
Head : normocephal
Face : symmetrical, not dysmorphic
Eyes : conjunctival anemic, sclera not jaundice
Neck : KGB enlargement (-)
Chest : no chest wall retraction
Abdomen : flat, bowel sound (+) normal, liver palpable 1-1 cm
below arcus costa, spleen not palpable
Extremities : warm, no cyanotic, capillary refill time less than 2 second

A Acute Lymphoblastic Leukemia B-Lineage relapse, induction phase

(C91.02) + Leukemia of the central nervous system (C91.00)

25
P Therapeutic :
- Dexamethasone 4 – 4 – 2
- L- asparginase (III) 6.375 U in NaCl 0,9% 500 ml
Nutritional care :
Solid food and side dishes 3 x 1 portion (@ 500kkal,7g protein,10g fat)
consists of :
• Rice ¾ cup, side dish (chicken 1 medium cut + “tahu” 1/2 large
cut), vegetables (50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
Water 1,500 ml / day

23rd July 2017 (4th observation day, 41st treatment day)

S Fever (-), bone pain (-), pallor (-), nausea (-), vomiting (-), good intake
O General condition : looked sick, compos mentis
Blood pressure : 90/60 mmHg Respiratory rate : 24 x/min
Pulse : 88 x/min, regular Temperature : 36,5oC(axilla)
Head : normocephal
Face : symmetrical, not dysmorphic
Eyes : conjunctival anemic, sclera not jaundice
Neck : KGB enlargement (-)
Chest : no chest wall retraction
Abdomen : flat, bowel sound (+) normal, liver palpable 1-1 cm
below arcus costa, spleen not palpable
Extremities : warm, no cyanotic, capillary refill time less than 2 second

A Acute Lymphoblastic Leukemia B-Lineage relapse, induction phase

(C91.02) + Leukemia of the central nervous system (C91.00)

26
P Therapeutic :
- Dexamethasone 4 – 4 – 2
Nutritional care :
Solid food and side dishes 3 x 1 portion (@ 500kkal,7g protein,10g fat)
consists of :
• Rice ¾ cup, side dish (fish 1 medium cut + “tempe” 1 medium cut),
vegetables (50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
Water 1,500 ml / day

24th July 2017 (5th observation day, 42nd treatment day)

S Fever (-), bone pain (-), pallor (-), nausea (-), vomiting (-), good intake
O General condition : looked sick, compos mentis
Blood pressure : 90/60 mmHg Respiratory rate : 28 x/min
Pulse : 88 x/min, regular Temperature : 36,6oC(axilla)
Head : normocephal
Face : symmetrical, not dysmorphic
Eyes : conjunctival anemic, sclera not jaundice
Neck : KGB enlargement (-)
Chest : no chest wall retraction
Abdomen : flat, bowel sound (+) normal, liver palpable 1-1 cm
below arcus costa, spleen not palpable
Extremities : warm, no cyanotic, capillary refill time less than 2 second

A Acute Lymphoblastic Leukemia B-Lineage relapse, induction phase

(C91.02) + Leukemia of the central nervous system (C91.00)

27
P Therapeutic :
- Dexamethasone 4 – 4 – 2
Nutritional care :
Solid food and side dishes 3 x 1 portion (@ 500kkal,7g protein,10g fat)
consists of :
• Rice ¾ cup, side dish (meat 1 medium cut + “tempe” 1 medium
cut, 1 egg), vegetables (50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
Water 1,500 ml / day

25th July 2017 (6th observation day, 43rd treatment day)

S Fever (-), bone pain (-), pallor (-), nausea (-), vomiting (-), good intake
O General condition : looked sick, compos mentis
Blood pressure : 100/60 mmHg Respiratory rate : 26 x/min
Pulse : 92 x/min, regular Temperature : 36,8oC(axilla)
Head : normocephal
Face : symmetrical, not dysmorphic
Eyes : conjunctival anemic, sclera not jaundice
Neck : KGB enlargement (-)
Chest : no chest wall retraction
Abdomen : flat, bowel sound (+) normal, liver palpable 1-1 cm
below arcus costa, spleen not palpable
Extremities : warm, no cyanotic, capillary refill time less than 2 second

A Acute Lymphoblastic Leukemia B-Lineage relapse, induction phase

(C91.02) + Leukemia of the central nervous system (C91.00)

28
P Therapeutic :
- Methotrexate intrathecal 12 mg
- Vincristine 1,215 mg in NaCl 0,9% 50 ml
- Daunorubicine 0,43 mg in NaCl 0,9% 100 ml
- L- asparginase (I) 6.375 U in NaCl 0,9% 500 ml
Nutritional care :
Solid food and side dishes 3 x 1 portion (@ 500kkal,7g protein,10g fat)
consists of :
• Rice ¾ cup, side dish (chicken 1 medium cut + “tempe” 1 medium
cut), vegetables (50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
Water 1,500 ml / day

26th July 2017 (7th observation day, 44th treatment day)

S Fever (-), bone pain (-), pallor (-), nausea (-), vomiting (-), good intake
O General condition : looked sick, compos mentis
Blood pressure : 90/60 mmHg Respiratory rate : 24 x/min
Pulse : 92 x/min, regular Temperature : 36,9oC(axilla)
Head : normocephal
Face : symmetrical, not dysmorphic
Eyes : conjunctival anemic, sclera not jaundice
Neck : KGB enlargement (-)
Chest : no chest wall retraction
Abdomen : flat, bowel sound (+) normal, liver palpable 1-1 cm
below arcus costa, spleen not palpable
Extremities : warm, no cyanotic, capillary refill time less than 2 second

A Acute Lymphoblastic Leukemia B-Lineage relapse, induction phase

(C91.02) + Leukemia of the central nervous system (C91.00)

29
P Nutritional care :
Solid food and side dishes 3 x 1 portion (@ 500kkal,7g protein,10g fat)
consists of :
• Rice ¾ cup, side dish (fish 1 medium cut + “tahu” 1 medium cut, 1
egg), vegetables (50 g)
• 1 cup milk 200 ml (@ 220 kcal, 7 g protein, 11 g fat)
Water 1,500 ml / day

IX. PROGNOSIS
Ad vitam : dubia ad malam
Ad functionam : dubia ad malam
Ad sanationam : dubia ad malam

30
 Disease Course Timeline
Observation period

May 25th 2017 May 27th 2017 May 28th - 31st 2017 June 1st 2017

Palpebral edema and dark colored Palpebral edema (+) Palpebral edema (-) Edema (-)
urine 1 week before admitted Dark colored urine (+) Dark colored urine (+) Dark colored urine (-)

GC: looked ill, CM
BP 120/80 mmHg;P 90 x/m;
RR 24 x/m;Temp: 37,1°C
Head: Facial edema (+)
Hb 11,3 g/dL, Ht 33,9%,
WBC 10.750/mm3,
PLT 235.000/mm3, Sod 137;
Pot 4,5; Cl 103,5;ureum 41 mg/dl,
Creatinin 1,3 mg/dl,
GFR 51,6 ml/mint /1,73m2,
ASTO 800 IU/mL
Urinalisis: RBC 40-45/hpf,
WBC 2-3/hpf, protein +2
CXR: normal cor and pulmo
EKG: rhytm sinus, P-R interval
normal
GC: looked ill, CM
BP 110/70mmHg;P 80 x/m;
RR 24 x/m;Temp 36,6°C
Palpebral edema +/+
Balance: -120 mL,
Diuresis:1,2 mL/kgBW/hour
Hb 11,5 g/dL, Ht 34,5%, WBC
10.100/mm3, PLT 249.000/mm3,
Sod 135; Pot 4,0; Cl 100; Ca 8,2
mg/dL, ureum 38 mg/dl,
Creatinin 1,2 mg/dl,
GFR 55,9 ml/min /1,73m2
GC: looked ill, CM
BP 110/70 mmHg;P 84 x/m;
RR 24 x/m; Temp 36,5°C
Balance: -150 mL,
Diuresis:1,3 mL/kgBW/hour
Urinalisis: RBC 20-30/hpf,
WBC 0-2/hpf, protein +2
Throat Swab :Streptococcus
pyogenes. Sensitive to Amikacin,
Amoxicilin, Ceftriaxone, Cefotaxime,
Ofloxacin, Meropenem, Ciprofloxacin,
Levofloxacin
C3: 25 mg/dL
GC: looked ill, CM
BP 90/60 mmHg; P 80 x/m;
RR 24 x/m;Temp 36,7°C.
Balance: +50 mL,
Diuresis: 1,7 ml/kgBW/hour
Hb 12,3 g/dL, Ht 36,9%, WBC
9.250/mm3, PLT 350.000/mm3, Sod 137;
Pot 4,5; Cl 102; Ca 8,5 mg/dL
ureum 21 mg/dl, Creatinin 0,9 mg/dl,
GFR 74,5 ml/min /1,73m2
 Acute glomerulonephritis post
streptococcus
 Acute Kidney Injury (Risk stage)

Acute glomerulonephritis post streptococcus

 Acute glomerulonephritis post
streptococcus
 Acute Kidney Injury (Injury stage)
 Amoxicilin 3 x 375 mg per oral
 Furosemide 2 x 20 mg per oral
 Fluid restriction (IWL+urine output)
 Protein 1 gr/kg/day
 Low salt dietary 1 g/day
Acute Kidney Injury (Injury stage)  Amoxicilin 3 x 375 mg per oral
 Furosemide 2 x 20 mg per oral
 Fluid restriction (IWL+urine output)
 Protein 1 gr/kg/day
 Amoxicilin 3 x 375 mg per oral  Low salt dietary 1 g/day
 Furosemide 2 x 20 mg per oral
 Fluid restriction (IWL+urine output)
 Protein 1 gr/kg/day
 Low salt dietary 1 g/day
31
 CASE ANALYSIS
A boy, 7 years and 3 moths old
 Facial edema 1 week before admitted
 Dark colored urine 1 week before admitted
 History of fever 2 week before admitted
 History of swallowing pain 2 week before admitted

Nephrology

Clinical symptoms &  Hematuria

Physical examination  Palpebral edema
 History of swallowing pain
 Blood pressure 120/80 mmHg

Laboratory and other Complete blood exam, ureum, creatinin, electrolite, ASTO,
examinaton albumin, throat swab, C3, urinalisis, chest x-ray, ECG,
kidney and urogenitalial system USG

Diagnosis  Acute glomerulonephritis post streptococcus

 Acute Kidney Injury (Injury stage)

Treatment  Antibiotic
 Diuretic
 Nutritional support
 Fluid restriciton

Problem Prognosis

 Med Sci Monit. 2015. Level of Evidence 2A, rekomendasi B

 Paediatr Indones. 2016. Level of Evidence 2B, rekomendasi B
 Indian J Pediatr. 2015. Level of Evidence 2B, rekomendasi B 32
 Int J Sci Std. 2015. Level of Evidence 2B, rekomendasi B

33