Morning Report Thursday, April 12st 2018: Mad/Rhs/Iss

Morning Report
Thursday, April 12st 2018

MAD/RHS/ISS
No Name Age Working Diagnosis
1. PR Boy, 14 years 2 - Hyperleucositosis ec DD/ AML
months ALL
+ malnutrition
1
New Patient of emergency room at 17.00 pm, PR, boy, 14 yo 2 mo,
address: Tarutung, Medan
BW : 37 kg BL : 152 cm
W/A : 72,5% H/A: 92,6% W/H : 88%
Arm circumference: 16,5cm (P<5th)
Chief complain : Pale

- It experienced since this week
- He had gum bleeding since 4 days ago. History of epistaksis was
not found. Bloody stool (+) in this two days. History of bloody
stool (+) 1 week ago.
- Pain was experience (+) on knee joint and elbow in this 4 months.
- Headache was found
- Fever (+) in this week, fever arise and missing with antipiretic drug.
- Breathlessness was not found
- History os seizure was not found
- Vomitus (+) since today. History of vomitus was not found
- Nausea was found.
- Weight decrease since 2 months ago,however parents never pay
attention about how much the number of the decrease.
- Urinary and defecation were normal
- History of fertilizer storage was not found
History of previous illness :
• He was refered from Tarutung Hospital with diagnosed hyperleucositosis
e.c suspec leukemia
History of previous medication :

• IVFD D5% NaCl 0,225% + Meylon 25cc 75cc/hour, inj Tranexamat acid
400 mg/8 hours, Codein 3x300 mg, inj paracetamol 800 mg/12 hours, Inj
ketorolac 22 mg/8 hours
• History of transfusion was not found
Family history : no family with blood disorder
Food recall : porridge half of portion with fish 1 piece (3 times a day), bread
1 piece.
Physical Examination
General status :
Alertness : GCS 15 (E4V5M6) Temperature : 38.4 C
dyspnoe (-), cyanosis (-), edema (-), icteric (-), anemic (+)
Localized status:
Head : Old man face (-), protrude of cheekbone (-)
Eye : Light reflexes (+/+), isochoric pupil Ø3mm/3mm, pale inferior palpebral
conjunctiva (+/+)
Ear/nose/mouth : within normal limit/ epistaksis (-)/ pale (+), gum
bleeding (+)
Neck : lymph node enlargement (-)

Thorax : Wide ribs space, protrude of vertebra,
Symmetrical fusiform, no retraction
Heart rate : 106 beat/minute, regular, murmur (-)
Respiratory rate : 22 rate/minute, regular, no rales, stridor, and wheezing
Abdomen : soft, peristaltic sound (+), hepar : hepatomegaly 10 cm under dextra

arcus costae, flat surface, sharp border, painfull (-). Spleen: Schufner 3
Anogenital : within normal limit
Extremities : hypotrophy muscle, pale (+), pulse 106 bpm, regular, warm
extremities, capillary refill time (CRT) < 3 second, O2 Sat : 99%
BP 100/70 mmHg
Lab of Tarutung Hospital
th
April 11 2018
• Hb : 8,9 g/dl • KGD : 96 mg/dL
• Ht : 28 %
• Leucocyt : 366.800/UL • Na : 128,7
• Trombocyte : 20.000/UL •K : 3,87
• Cl : 95,15
• Eosinofil :0,4
• Basofil : 34,2
• Neutrofil : 34,2
• Limfosit : 27,1
• Monosit : 26,6
Lab of Tarutung Hospital
th
April 11 2018
• Color yellow Sedimen :
• BJ : 1,010 • Eritrosit : 1-2/lp
• pH : 6,0 • Leucosyt : 4-5/lp
• Protein : negative • Kristal :-
• Reduction : negative • Epitel : 1-2/lp
• Bilirubin : negative
• Keton : negative
• Nitrit : negative
• Urobilinogen : negative
• Blood : negative
Differential Diagnosis:
- Hyperleucositosis ec AML + severe malnutrition
- Hyperleucositosis ec ALL + severe malnutrition
Working diagnosis :
Hyperleucositosis ec AML + severe malnutrition
Therapy :
• Nasal cannula Oxygen 1-2 liter/minute
• Hydration with IVFD D5% NaCl 0,225% 2xmaintenance =26 cc/hour (macro) for
24hr
• Allupurinol 3x125 mg
• Paracetamol tab 3x500mg
• D10% 50 cc per oral
Planning
- Laboratory : complete blood count, urinalysis, electrolyte, RFT, uric acid, Blood
Gas Analysis, blood smear
- Urine output and fluid balance examination every 6 hr, if pH urine< 6,5 add 1
flash meylon 25 mEq every 500 cc D5% NaCl 0,225%
- Chest X Ray
- Consult to hemato-oncology division
Time Sensorium HR RR Sat.O2 Tempt Additional
18.00 GCS 15 100 22 x/ 98% 38.4

bpm menit
19.00 GCS 15 96 bpm 22 x/ 96% 38.4 Took blood sample for

menit laboratory examination
19.00 GCS 15 100 20x/ 98% 38.2 Start hydration with IVFD
bpm menit D5% NaCl 0,225%
2xmaintenance
20.00 GCS 15 100 20x/ 98% 38.2 Dipstik urine : Leu (-)/Nit(-)/
bpm menit Uro (0,2)/Pro (+15)/pH (6)/
Blo (-)/SG(1,015)/Bil(-)/Glu(-)
 give 1 flash Meylon to
IVFD D5% NaCl 0,225%
500CC
Time Sesorium HR RR Sat.O2 Tempt Additional
20.30 GCS 15 100 22 x/ 98% 38 Patient referred to RB4

bpm menit

Morning Report Thursday, April 12st 2018: Mad/Rhs/Iss

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Morning Report

Thursday, April 12st 2018

Chief complain : Pale

History of previous medication :

Family history : no family with blood disorder

Neck : lymph node enlargement (-)

Abdomen : soft, peristaltic sound (+), hepar : hepatomegaly 10 cm under dextra

Anogenital : within normal limit

18.00 GCS 15 100 22 x/ 98% 38.4

19.00 GCS 15 96 bpm 22 x/ 96% 38.4 Took blood sample for

20.30 GCS 15 100 22 x/ 98% 38 Patient referred to RB4

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