Name

: Eka Septiyani
Age
: 17 years 10 months old
Admitted to hospital
: August 6th, 2016
Diagnosis
: Osteosarcoma post amputation, efusi pleura
caosed by pulmo and pleural metastation
Date of Diagnosis
:
Therapy started on
: 24 Desember 2013 April 2014
Complaint
: shortness of breath
Patient complained having cough and losing appetite approximately 2 months
before admission. There was no fever. 1 month before admission she started feeling
shortness of breath and the cough still persists.
Previous history :
The patient was diagnosed Osteosarcoma on Cruris dextra on Desember
2012. She started the Chemotherapy protocol from 24 Desember until April
2014. The Amputation was helded at 24 Desember 2013.
After finishing the protocol, the patient had no complaints. She visited the
Hemato-oncology clinic for blood testing every 6 months. She claimed that
she never underwent x-ray examination during the period time after finishing
the protocol until day of admission.
Physical findings
mentis.

: General appearance looked weak,pale, compos

wellnourished patient.
Decrease of vesicular sound in pulmo dextra
other examinations are normal.

Laboratory findings :

Hemoglobin
(g/dl)
Platelet count
(/uL)
Leukocyte count
(/uL)
ANC (/uL)
BUN (mg/dl)
Creatinin (mg/dl)
AST (u/l)
ALT (u/l)
Albumin (mg/dl)

August 6th
2016
8,8

Reference

453.000
16.000
12.560

2.86

From the Thorax CT Scan : mass in pulmo dextra with calsification at lobus
medius and inferior of pulmo dextra with Effusion in pleural dextra. High

possibility being pulmonal metastase. There is no sign of skeletal

mettastase.

Therapy /plan :

Is there a chemotherapy regimen for metastase of osteosarcoma or a

possibility for radiotherapy
In this case the metastase wasnt detected until 2 years, is there some kind
of screening protocol follow up for post chemotherapy and amputation of
osteosarcoma?

Result of the discussion :

FORM B: TELECONFERENCE
Date of teleconference:
Type of teleconference:
Technical problem:
Indonesia:
Attendance list:
Verbally presented by:
Format filled in by:
Netherlands:
Attendance list:
Verbally presented by:
Format filled in by:

Day:Tuesday Month: August

Year:2016
Skype/ email
Yes/ no
Pediatric oncologists: n=
Residents: n=
Pediatricians:
n=
Other (specify):
Pediatric oncologist/ Fellow / Resident/ Other (specify):
If not oncologist, reason:
Pediatric oncologist/ Fellow / Resident/ Other (specify):
Pediatric oncologists: n=
Residents: n=
Pediatricians:
n=
Other (specify):
Pediatric oncologist/ Fellow/ Resident/ Other (specify):
If not oncologist, reason:
Pediatric oncologist/ Fellow / Resident/ Other (specify):

DEMOGRAPHICS
Name of patient:
Hospital number:
Date of birth:
Gender:
Distance home to hospital:
Shelter home
Type of health-insurance:
Hospital class :

Eka Septiyani
01.64.90.57
Day:
18
female

Month: 09

Year: 1998

Public insurance
3

DIAGNOSTICS: CURRENT STATUS

If yes, specify + date:
Clinical diagnosis:
Physical examination:
Lab:
Imaging:
PA:
Consultant:
Is PA conclusive?
Is staging complete?
If yes, specify + date:
Has working diagnosis been
made?
Has work diagnosis changed
during course of disease?

Yes
Yes
Yes
Yes
Yes
No

Yes
Yes
Yes
No

DIAGNOSTICS: REQUEST FOR CONSULTATION BY INDONESIA

If yes, specify:
Has Indonesia requested
consultation about diagnostics?

Yes

DIAGNOSTICS: EVALUATION BY NETHERLANDS

Do current diagnostics need
adjustments?

Yes/No

DIAGNOSTICS: ADVICE BY NETHERLANDS

If yes, specify:
Revision PA:
Physical examination:
Lab:
Imaging:
Consultant:
Other:

Yes/no
Yes/no
Yes/no
Yes/no
Yes/no
Yes/no

TREATMENT: CURRENT STATUS

If yes, specify + date:
Is patient receiving treatment?
Is a treatment protocol used?
Has treatment protocol changed
during course of treatment?

Yes/no

Yes

Yes/no
Yes/no

Yes, Hystiocytosis protocol

Not yet

TREATMENT: REQUEST FOR CONSULTATION BY INDONESIA

If yes, specify:
Has Indonesia requested
consultation about treatment?

Yes

Yes

TREATMENT: EVALUATION BY NETHERLANDS

Does current treatment need
adjustments?

Yes/no

TREATMENT: ADVICE BY NETHERLANDS

If yes, specify:
Consultant:

Yes/ no

Change of protocol:
Change into palliative care:
Timing of chemotherapy course:
Change of chemotherapy doses:
Transition from curative to
palliative treatment:
Antibiotics Dosage:
Antibiotics Duration:

Yes/no
No
No
No
No

Nutrition:

Yes/ no

Pain relief:

Yes/ no

Transfusions:
Antiemetics:

Yes/ no
Yes/ no

Prevention tumor lysis

syndrome:
Bladder protection:

Yes/ no

Hygiene and living rules:

Yes/ no

Other:

Yes/ no

Yes/ no
Yes/ no

Yes/ no

NAME OF PATIENT
HOSPITAL NUMBER

:
:

HOSPITAL CLASS AT DIAGNOSIS: .

FORM C: MEDICAL RECORDS

DIAGNOSTICS: MEDICAL RECORDS FOLLOW-UP
DUTCH ADVICE:
If yes: MEDICAL RECORDS:
CODE:
Physical examination:
Yes
Done
Lab:
Yes
Done
Imaging:
Yes
Done
Revision PA:
No
Done/not done
Consultant:
Yes/ no
Done/not done
If non-compliance, reason:(more than 1 answer allowed)
A Dutch advice:
1.Unclear/ 2.Complex/ 3.Disagreement/ 4.Insignificant/ 5.Not
applicable in low-income setting
B Health-care
Doctor:
1.Forgetting/ 2.Lack of time/ 3.Lack of knowledge/
providers Indonesia:
4.Unavailable/ 5.Refusal
Consultant: 6.Forgetting/7.Lack of time/ 8.Lack of knowledge/
9.Unavailable/ Refusal
C Facilities Indonesia:
1.Unavailable PA method/ 2.Unavailable imaging device/
3.Unavailable lab test/ 4.Waiting list
D Parents/ patient :
1.No money/ 2.No health-insurance coverage/ 3.Refusal parents or
child/ 4.Treatment abandonment/ 5.Religion/ 6.CAM/ 7.Fear/ 8.Family
conflict/ 9.Forgetting/ 10.Poor condition child/ 11.Patient died/
12.Travel distance
E Other (specify):

TREATMENT: MEDICAL RECORDS FOLLOW-UP

DUTCH ADVICE: If yes, MEDICAL RECORDS:
Consultant:
Yes
Date:
Change of protocol:
No
Date:
Change into palliative
No
Date:
care:
Timing of chemotherapy
No
Date:
course:
Change of chemotherapy No
Date
doses:
Transition from curative
No
Date:
to palliative treatment:
Antibiotics Dosage:
Yes
Date: October
1st 2015
Antibiotics Duration:
Yes
Date:
Nutrition:
Yes
Date:

CODE
Done
Done/ not done
Done/ not done
Done/ not done
Done/ not done
Done/ not done
Done
Done/ not done
Done/ not done

Pain relief:
Transfusions:
Antiemetics:
Prevention tumor lysis
syndrome:
Bladder protection:
Precepts of living:
Other (specify):

No
Yes
No
No

Date:
Date:
Date:
Date:

Done/ not done

Done/ not done
Done/ not done
Done/ not done

No
No
No

Date:
Date:
Date:

Done/ not done

Done/ not done
Done/ not done

If non-compliance, reason:(more than 1 answer allowed)

A Dutch advice:
1.Unclear/ 2.Complex/ 3.Disagreement/ 4.Insignificant/ 5.Not
applicable in low-income setting
B Health-care
Doctor:
1. Forgetting/ 2. Lack of time/ 3. Lack of knowledge/ 4.
providers Indonesia:
Unavailable/ 5. Refusal
Consultant: 6. Forgetting/ 7.Lack of time/8. Lack of knowledge/
9.Unavailable/ 10.Refusal
C Facilities Indonesia:
1.Unavailabledrugs/ 2.Unavailable nutrition/ 3.
Unavailable transfusions/ 4.Waitinglist
D Parents/patient:
1.No money/ 2.No health-insurance coverage/ 3.Refusal parents or
child/ 4.Treatment abandonment/ 5.Religion/ 6.CAM/ 7.Fear/ 8.Family
conflict/ 9.Forgetting/ 10.Poor condition child/ 11.Child died/ 12.Travel
distance
E Other (specify):