Morning Report

Friday , March 22 th 2019

ITL/RMS/FPL
No Name Age Working Diagnosis
1. AG Boy, 1 suspect Leukemia
years
AG, boy ,1 years arrived in Emergency Room at 19.00 a.m,
adress at Medan.
BW : 9,5 Kg , Height : 70 cm
W/A = 0<Z< -2 H/A =-3< Z < 2 W/H= 0 < Z < 2

Chief complain: Pale

• This has been experienced since 1 weeks ago, and getting
worse within 2 days ago.
• History of fever was found 1 days ago, in emergency room
fever was not found.
• History of gum or nose bleeding and dark stool was not
found.
• Dark urine like “cola” was found since 1 day ago.
• Cough and shortness of breath was not found.
• Naussea and vomiting was not found.
• defecation was normal.
• History of exposure to pesticide was not found.
• History of illnes:
The Patient was old patient of Hemato-oncology divison
with diagnosed with suspect Leukemia, with result bone
marrow pucture (BMP): dailuted marrow ( advice : repeat
BMP again)

• History of medication :
Unclear
Physical Examination
Presence Status:
Sensorium: Compos mentis Temperature :370 C
Anemia (+), Icteric (-), Cyanosis (-), Dyspnea (-), Edema (-)

Localized status:
Head : Eye : light reflexes (+/+), isochoric pupil Ø2mm/2mm,
pale inferior palpebral conjunctiva was found (+/+)
Ear : within normal limit
Nose : within normal limit
Mouth: within normal limit.
Neck : Lymph node enlargement was not found
Thorax : Symmetrical fusiform, no retraction
Heart rate : 130 beat/minute, regular, no murmur
(N: 60-120)
Respiratory rate : 24 time/minute, regular, no rales
(N: 16-20)
Abdomen : soft, peristaltic sound (+), liver was palpable 3 cm
under arcus costae, Lien was palpable Schufnerr
II/III
Extremities: Pulse 130 bpm, regular, warm extremities,
capillary refill time < 2 second, BP: 95/60 mmHg
Differential Diagnosis
Acute Leukemia ec DD :
1. Acute Lympoblastic leukemia
2. Acute Myeloblastic leukemia
Therapy:
• IVFD D5% NaCl 0,225% 30 cc/hour

Planning
- Cek Full Blood count, Glucose ad random
- Consult to hemato-oncology division
- BMP
 Follow up
time Sensoriu BP HR RR T
m
19.00 CM 90/60 92 20 36 Bood sampling was taken
,9
19.45 CM 90/60 92 20 37 Critical value :
Leu 328.000/ Hb 5,8 / T 19.00
20.00 CM 90/60 98 20 37 Patient was transferred to the
,0 ward
Working diagnosis:
Hyperleukocitosis ec. Acute Leukimia DD
1. Acute Lympoblastic leukemia
2. Acute Myeloblastic leukemia
Therapy :
- Hidration with 2 times maintenance fluid -> IVFD
D5% NaCl 0,225 % 79 cc/hour
- Catheter urin
- Fluid balance / 6 hours
- Dipstick urine/ 6 hours, if PH below 6,5 give meylon
in hidration fluid.
 Follow up
time Sensoriu BP HR RR T
m
20.1 CM 90/60 98 20 37,0 Patient was transferred to the
ward
Thank You