MORNING REPORT

SATURDAY, 16 TH APRIL 2017

dr. Sandi / dr. Krisby

dr. Aya / dr. Debby / dr. Ifa / dr. Ahimsa / dr. Cempaka
dr. Guntur / dr. Rini
dr. Rara / dr. Irfan

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 PATIENT ADMISSION

MELATI 2 WARD
child F, boy, 3.5 y.o, 10 kgs, acute diarrhea without dehidration,
relapsed abberant type AML M2 during first week chemotherapy,
polyuria, marasmic type malnutrition
Child D, boy, 4.5 y.o, 14 kgs, epistaxis e.c trombocytopenia, micrositic
hypochromic anemia due to chronic infection dd/ Fe deficiency, PNET during
3rd cycle of chemotherapy
HCU NEONATUS:
Baby Ms.S, babyboy, 0 day, 2800 grams, caput succedaneum dd/ cephal
hematoma, neonate, appropiate for gestational age, vacuum extraction
delivery due to prolonged labour and severe preeclampsia
PICU : -
HCU MELATI 2 : -
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 PATIENT IDENTITY

Name :F
Sex : Male
Age : 3.5 y.o
Body weight : 10 kgs
Adress : Kedung Rejo, Sukoharjo
Medical Record : 01333660

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CHIEF COMPLAINT

Fever

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 CURRENT MEDICAL HISTORY

3 days before admission 1 day before admission

Fever (38-39.70 C ) Patient still had fever

The temperature decreased Vomit 4 times a day since
after took paracetamol morning
Excessive urinating 10 Vomit consist of gastric juice,
times a day no mucous or blood
Urine volume was 1.5 litres a Patient also had diarrhea 3
day times, no mucous or blood
Excessive drinking Sign of dehydration (-)
Weight loss (-) Cough (+), phlegm (+)
Fatigue and weakness (-) Breathlessness (-)
Vomit (-) Abdominal pain (-)
Nausea (-) Emergency Room RSUD Dr.
Breathlessness (-) Moewardi
Bleeding manifestation
epistaxis, gummy bleeding,
melena were denied
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 PAST MEDICAL HISTORY

Hospitalization history :
Patient had been hospitalized on April 5th
2017, diagnosed as Relapsed AML M2
Abberant type , severe neutropenia fever,
bleeding due to thrombocytopenia.
Patient got chemotherapy the last
regimens of chemotherapy were cytarabine
and metothrexate

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 FAMILY MEDICAL HISTORY

History of same illness in family was denied

History of malignancy was denied

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 PREGNANCY AND DELIVERY HISTORY

During pregnancy, his mother routinely checked her pregnancy to

midwife. She was given vitamin, and she didnt consume any
medicine besides it. She hasnt got hospitalized during pregnancy
Baby boy was born in 40 weeks of pregnancy, C-section delivery
because of chephalo-pelvic disproportion, crying vigorously,
cyanosis or icteric wasnt found. His birth weight was 3000 grams,
his mother forgot his birth length

Conclusion: Pregnancy and delivery history were normal

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 VACCINATION HISTORY

BCG : 1 month
Hepatitis B0 : 0 month
DPT-HB : 2,3,4 months
Polio : 1, 2,3,4 months
measles : 9 month

Conclusion : complete immunization, appropriate

with Ministry of Healths schedule 2010

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 NUTRITION HISTORY
Patient eats 1 - 2 times a day, rice with tahu, tempe, often meat, fish,
vegetables. the portion of meal is 1/3-1/2 portion. Patient easily got
thirsty but not hungry.
Conclusion: nutrition status is not adequate

GROWTH AND DEVELOPMENT

He is now 3,5 years old, can communicate well with family and his
friends
His weight is 10 kg with body height 87 cm.
Conclusion: inappropriate for his age
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 NUTRITIONAL STATUS

Weight for Age: W/A < -3 SD

Height for Age: H/A < -3 SD
Weight for Height : -2SD< W/H < -3SD
Mid upper arm circumference = 9.5 cm

Conclusion:
wasted, severely underweight, severely stunted
malnutrition
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 FAMILY TREE

II

III

child. F, 3.5 years old

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 PHYSIC AL EXAMINATION

General appearance : moderatel ill, fully alert,

GCS E4M6V5
Vital sign :
Heart Rate = 145 bpm
Respiration rate = 36 bpm
Temperature = 39,5 0 C peraxilar
O2 saturation = 98%
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 Face : old man face (+)
Head: mesocephal, head circumference =46 cm (-2SD < head
circumference < 0, Nelhaus)
Eyes : pale conjunctiva (+/+), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm, sunken eyes (-/-), tears (+/+)
Nose : nasal flare (-/-), discharge (-/-)
Mouth : wet lips (+), lips and tongue not cyanotic, multiple dental
caries (+)
Neck: no enlargement of lymph node
Thorax : symmetric (+), retraction (-), prominent ribs (+)

LUNG:
I: normal, symmetric, no retraction
P: fremitus equal on both sides of hemithorax
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (-/-)
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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall more prominent than chest wall
A: peristaltic sounds in normal limit
P: dullness (+) almost in whole abdomen, shifting dullness (-), undulations(-),
P: liver was palpable 8 cms larger below right arch costae , the consistency was
tender, sharp edge. Spleen was palpable at Schuffner VI, abdominal
circumference = 52 cm, good skin turgor

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly
palpable

GENITALIA : , no abnormality
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 LABORATORY FINDINGS

Hb : 5.2 g/dl Blood sugar : 104 mg/dl

HCT : 16% Sodium : 130 mmol/L
AL : 42.0 thousand/ul
Potassium : 3.5 mmol/L
AT : 37 thousand/ ul
AE : 1.71 mil/ul Chloride : 99 mmol/L
MCV : 93.9/um Calcium : 1.15 mmo/L
MCH : 27.1 pg
MCHC : 28.9 g/dl Conclusion :
Netrophyl : 26.00%
- Microcytic hypochromic
Limphocyte : 24.00%
anemia
Monocyte : 13.00 %
- Hyponatremia
LUC/AMC
(large undifferentiated cell/ - Leukocytosis
Atypical mononucleated cell - thrombocytopenia
: 37, 00%
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 LABORATORY RESULTS

URINALYSIS
Colour = yellow, Cloudy (-)
BJ = 1.015
pH = 5.5
Leucocyte = Negative
Nitrite = negative
Protein = negative
Glucose = normal
Ketones = negative
Urobilinogen = normal
Bilirubin = normal
Erythrocyte = negatif
Conclusion : urinalysis was normal
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 LIST OF PROBLEM

A chlid, male, 3.5 years old with :

High Fever 3 days before admission Temperature = 39,50 C
Polyuria Old man face
Polydipsia Pale conjunctiva
Carries dentis multiple
Vomit 4 times a day
prominent ribs
Diarrhea 3 times a day, watery, no
mucous, no blood Abdomen : distended,
hepatospleenomeghaly, abdominal
Patient has been diagnosed with circumference = 52 cm
relapsed AML M2 abberant type
Mycrocitic hypochromic anemia
during 1st week chemotherapy
Leukocytosis
No adequate intake
thrombocytopenia
MUAC = 9.5 cm
Hyponatremia
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 DIFFERENTIAL DIAGNOSIS

Acute diarrhea without dehydration

Relapsed AML M2 abberant type during 1st
week chemotherapy
Polyuria due to suspected for diabetes
insipidus central dd nephrogenic
Malnutrition marasmic type

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 WORKING DIAGNOSIS

Acute diarrhea without dehydration

Relapsed AML M2 abberant type during 1st
week chemotherapy
Polyuria due to suspected for diabetes
insipidus central dd nephrogenic
Malnutrition marasmic type

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 THERAPY

Admitted to pediatric hemato-onkology ward

10 steps of malnutrition management:
1. Prevent hypoglicemia resolved
2. Prevent hypothermia resolved
3. Prevent dehydration by giving Resomal 50 ml/vomit, 100 ml/diarrhea
4. Manage electrolyte imbalance by giving mineral mix and F75
5. Manage infection give antibiotics Cefotaxime injection (50mg/kgBW/8 hours) ~
500 mg /8 hours, Gentamycin injection (7.5mg/kgBW/24hours ) ~ 75 mg/24 hours
6. Manage lack of micronutrient give folic acid 5mg first day, then 1mg/day, zinc
20mg/day, vitamins
7. Give food for stabilization and transision phase
Nutrition : F75 based on appropiate phase ( 12x 85cc) his parents refused
this treatment
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 THERAPY

Paracetamol injection (10mg/kgBW/6hours) ~ 100 mg/6

hours
PRC Transfusion 1 kolf

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 PLAN

1. Ureum/creatinine,
2. Urine and stool analysis
3. Blood culture

MONITORING

General appearance / vital sign / fluid balance /

diuresis / hydration status every 4 hours
Check blood glucose every 24 hours

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 FOLLOW UP 17 TH APRIL 2017

General appearance : moderatel ill, fully alert,

GCS E4M6V5
Vital sign :
Heart Rate = 132 bpm
Respiration rate = 30 bpm
Temperature = 38,5 0 C peraxilar
O2 saturation = 98%
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 Face : old man face (+)
Head: mesocephal, head circumference =46 cm (-2SD < head
circumference < 0, Nelhaus)
Eyes : pale conjunctiva (+/+), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm, sunken eyes (-/-), tears (+/+)
Nose : nasal flare (-/-), discharge (-/-)
Mouth : wet lips (+), lips and tongue not cyanotic, multiple dental
caries (+)
Neck: no enlargement of lymph node
Thorax : symmetric (+), retraction (-), prominent ribs (+)

LUNG:
I: normal, symmetric, no retraction
P: fremitus equal on both sides of hemithorax
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (-/-)
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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall more prominent than chest wall
A: peristaltic sounds in normal limit
P: dullness (+) almost in whole abdomen, shifting dullness (-), undulations(-),
P: liver was palpable 8 cms larger below right arch costae , the consistency was
tender, sharp edge. Spleen was palpable at Schuffner VI, abdominal
circumference = 52 cm, good skin turgor

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly
palpable

GENITALIA : , no abnormality
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 WORKING DIAGNOSIS

Acute diarrhea without dehydration

Relapsed AML M2 abberant type during 1st
week chemotherapy
Polyuria due to suspected for diabetes
insipidus central dd nephrogenic
Malnutrition marasmic type

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 THERAPY

Nutrition : F75 (12x 85cc) his parents refused this treatment

Cefotaxime injection (50mg/kgBW/8 hours) ~ 500 mg /8 hours
Gentamycin injection (7.5mg/kgBW/24hours ) ~ 75 mg/24 hours
Paracetamol injection (10mg/kgBW/6hours) ~ 100 mg/6 hours
Mineral mix cth /24 hours
Vitamin C 50 mg/ 24 hours
Vitamin B complex 1 pill/ 24 hours
Zinc 20 mg/24 hours
Resomal 50 ml/vomit, 100 ml/diarrhea

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 PLAN

1. Ureum/creatinine,
2. Urine and stool analysis
3. Blood culture

MONITORING

General appearance / vital sign / fluid balance /

diuresis / hydration status every 4 hours
Check blood glucose every 24 hours

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 WHAT IS THE MOST FREQUENT
C AUSE OF POLYURIA IN CHILDREN
WITH AML?

P : children with AML

I :-
C :-
O : cause of polyuria in children with AML
THANK YOU

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