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NC Rara Hema

The document summarizes a clinical case of a 9-year-old female patient presenting with bleeding spots and fever. She was referred from another hospital with a diagnosis of aplastic anemia or possible leukemia. Her examination revealed pancytopenia. Laboratory tests showed anemia, thrombocytopenia, and severe neutropenia. Her assessment included differential diagnoses of leukemia vs aplastic anemia. Her treatment plan included antibiotics, analgesics, platelet transfusions, and further evaluation with bone marrow biopsy and immunophenotyping.

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Dodi Di
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17 views

NC Rara Hema

The document summarizes a clinical case of a 9-year-old female patient presenting with bleeding spots and fever. She was referred from another hospital with a diagnosis of aplastic anemia or possible leukemia. Her examination revealed pancytopenia. Laboratory tests showed anemia, thrombocytopenia, and severe neutropenia. Her assessment included differential diagnoses of leukemia vs aplastic anemia. Her treatment plan included antibiotics, analgesics, platelet transfusions, and further evaluation with bone marrow biopsy and immunophenotyping.

Uploaded by

Dodi Di
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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CLINICAL CONFERENCE

HEMATOLOGY ONCOLOGY DIVISION


(New Case)
August 08th, 2023
Dhody Setiamal/ Junior Divisi
L.M. Isvan Davis. Nurul Hikmah/ Madya Divisi
Liesa Ferawaty Lesomar, Irwandi Zakaria, Novian Sollina Eoh, Eunike Jaequeline
Salipadang
/ Senior Divisi
PATIENT IDENTITY
R.I, 9 years 8 month old (Female)
MR Number 1036078
Date of Birth Nov 16th, 2013
Admission Date August 08, 2023

MEDICAL DIAGNOSIS
Leukemia differential diagnosis Aplastic anemia
+Trombositopenia+Febrile Neutropenia (severe neutropenia)
+Acute faringitis
Chief Complaint HISTORY TAKING
Bleeding spot
History of Present Illness
A girl 9 years old 8 month referred from Kendari Hospital with diagnosis
Aplastic anemia differential diagnosis leukemia.
The girl admitted to hospital with chief complaint bleeding spot in upper and
lower extremity 14 days ago before admitted to hospital.
There no fever, history fever 2 weeks ago, continuous fever,
There was pain throath
No seizures.
No cough, no shortness of breath
good appetite
Defecation: normal, yellow
Urination: normal, yellow
HISTORY TAKING
History of Past Illness
- There was pale 2 weeks ago
- There was No history of frequent fever
- There No history of bleeding gums, epistaxis, reddish urine and melena
- There was No history of joint pain
- History of weight loss is not noticed
- there was no family history of malignancy.
- No history of living near rice fields.
- There was history of being treated 6 days at kendari hospital and received packed red
cell/intravena and trombosit/intravena
History of Vaccine PHYSICAL EXAMINATION
Month Years
Vaccine No 0 1 2 3 4 5 6 7 8 9 12 15 18 24 3 5 6 7 8
t
giv
en
Hep B V V V V V
BCG V
DPT V V V V
Hib V
OPV V V V V
IPV v

Measles V v
Rotavirus V
Influenza V
Japanese Encephalitis V

PCV V
Varicella V
Hepatitis A V

Typhoid V
PHYSICAL EXAMINATION
Vital Sign Antropomethry
General condition: Moderate illness/ Body weight : 41,5kg
Overweight/GCS 15 (E4M6V5)
Length : 143 cm
Blood pressure : 90/60 mmhg
Head circumference: 53 cm ( Normal 49-55 cm)
Heart Rate : 105 times/min
Anthropometry:
Temperature: 36,8°C Weight for heigth: 41,5/36 x100%= 115%
Respiration Rate : 27 times/min (Overweight)
SpO2 : 99 % Weight for age: 41,5/33 x100%= 125%
(overweight)
Pain Scale : 0 NRS
Height for Age: 143/136 x100% = 103%
( normal stature)
Head circumference: 53 cm ( Normal 49 -55 cm)
Weight for heigth: 41,5/36 x100%=
115% (Overweight)
Weight for age: 41,5/33 x100%= 125%
(weight)
Height for Age: 143/136 x100% = 103%
( normal stature)
PHYSICAL EXAMINATION
There was no pale. No icterus Genitalia
No stomatitis normal
Pharynx Hyperemesis
Tonsil T1-T1 not hyperemis Extremities
There was no Lymphadenopathy Warm acral, , CRT < 3 detik
Pulmo
Vesicular breath sounds.
Manifestations of spontaneous bleeding :
No rhonki no wheezing.
Petechiae at upper and lower ekstremity,
Bleeding time (ivy metode) : 8 menit 30 second
Cardiovascular
Rumple leed: positif
I / II heart sound, Regular rhythm
no murmur
Abdomen
Peristalsis was normal,
Hepar and spleen not palpable
LABORATORY FINDING
Kendari Kendari Kendari Kendari Wahidin
Laboratory Normal Value
31/07/23 03/08/23 04/08/23 06/08/23 08/08/23

Hb 7,5 11,9 11,4 11,3 10,7 12.0 – 16.0 gr/dL


WBC 1.200 1.650 2.660 2.240 2.500 4.0 – 10.0/μL
ANC 202 196 85 89 107 >2000
150.000 –
PLT 4.000 63.000 57.000 84.000 21.000
400.000/mm3
MCV 86 83,4 83,4 82,7 79 80 -100 μm3
MCH 28,5 28,6 28,9 29,4 28 27 - 32 Pg
%NEUT 16,9 11,9 3,2 4 4,3 52 – 75 103/μL
%LYMPH 69,2 85,7 94 93 93,3 20 – 40 103/μL
%MONO 9,9 2 1,2 1,6 2 2 – 8 103/μL
Ret 0,24 0,5 – 1 /μL
Wahidin
Laboratory 08/08/23
Normal Value

GDS - 103 140 gr/dl


Ureum - 14 10 - 50 mg/dl

Creatinine - 0,66 <1.3 mg/dl


SGOT - 11 < 38 u/l
SGPT - 10 < 41 u/l
Albumin - 3,4 3.5 – 5.0 mg/dl
136-145
Natrium - 137

Kalium - 3,8 3,5-5,1


Clorida - 102 97-111
LABORATORY FINDING
Peripheral blood smear kendari hospital 31/07/2023
Erythrocytes: Anisopoikilocytosis, normochromic normocytic, inclusion bodies
(-), normoblast (-)
Leukocytes: decreased, Lymphocytes>PMN, lymphocytes increase, pleomorfik
cell (-)
Platelets: decreased, normal morphology
Impression:
-Pancytopenia et causa suspected aplastic anemia
ASSESMENT
1. Bleeding spot
2. Fever
3. Pain of throath
4. Anemia
5. Trombositopenia
6. Febrile neutropenia(severe neutropenia)
7. Faringitis acute
ASSESMENT
1. Leukemia differential diagnosis Aplastic anemia
2. Trombositopenia
3. Febrile neutropenia (severe neutropenia)
4. Acute Faringitis
TREATMENT
- Infusion Dextrose 5%/intravenous
- 1) cefotaxime 1 gram/12 hours/intravenous
- Paracetamol 500mg/8 hours/intravenous
- Platelet transfusion/12hours/intravenous –
- Evaluation of spontaneous bleeding manifestations
- Evaluation of tissue anoksia
Planning
- Leukemia tracking : Bone Marrow Puncture (family agrees) and
immunophenotyping (family agrees)
THANK YOU

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