Good morning to prof. and doctors, my name is Eva, thank you for the opportunity.

Today I will report my case

with the title,
Febrile neutropenia, severe anemia and severe thrombocytopenia et causa acute lymphoblastic leukemia
(L2) high risk, moderate malnutrition.

I. CASE IDENTITY KASUS 0,5’

Name : AG
Sex : Male
Age : 2 years 10 months
2’
II.HETEROANAMNESIS  parents
Chief complaint: Pale
1. History of present illness
Pale was noticed by parents two weeks before admission. The patient looked pale on the face, lip,
both palm and foot. Pale was accompanied by weakness, fatigue, and shortness of breath. Patient
also complained bruises in right leg and red spot in auricle. There were no complaints about nose
bleeding, gum bleeding, bloody vomiting, dark-colored urine, bloody diarrhea nor bloody stool,
limb pain, acute diarrhea, prolonged diarrhea before being pale. Patient is not a vegetarian or had
eating habit unsual substances such as paint, dirt, hair, clay, glue, or ashes. Patient was given
anthelminthic routinely, the last anthelminthic was given on August 2017. No swelling and
yellowish on eyes or skin.
Patient had fever since one and half month before admission but it getting worse five days
before admission. Fever was observed whole day and every day with the highest-measured
temperature was 38.30C. Fever was getting better with medication that was given by parent every
four hours, however temperature were never reached below 37.50C. There were no complaints about
chills, abdominal pain, seizure, loss of consiousness, cough, cold, diarrhea, constipation, and joint
pain before nor during fever. No episode of red rash was appeared on the skin. There was no history
of taking medicine such as chemotherapy and antibiotic for a long period. There were no history of
travelling to eastern part of Indonesia such as Papua, Maluku, Sulawesi, and Nusa Tenggara before
fever episode.
Appetite and activity decreased since the symptoms appeared. Appetite did not improve with
changing the type of food. There was no progressive weight loss before the symptoms appeared.
Patient defecated once every two days, with yellow colour and solid consistency. It was no
dark nor bloody stool were observed. History of defecation accompanied by itching or worms out of
anal area during night were denied. Urination was normal, with clear yellow-color. Redness or
bubbling urine were not observed.
2. History of past illness 1,5’
The patient had been diagnosed with ALL (L2) on April 2018 but did not take any chemotherapy
because parents still denial
3. Family medical history
Patient was the only child and there was no family member who has similar complaints.
Conclusion: Family have no history of chronical disease.
4. Social history
a. Prenatal history
No problems during pregnancy, there was exposure of tobacco smoke.
b. Intranatal history
Patient was born spontaneously, vigorous and her body weight was 3400 gram  no problems
during delivery
c. Postnatal history
No history of hospitalization was reported, there was exposure of tobacco smoke.
d. Nutritional history
Patient were exclusively breastfed for 6 months, started soft food thereafter and adult food since
1 year old. Total calories intake 24 hours before admission were fulfilled 74% of RDA.
Conclusion: decreased food intake history after symptoms appear.
e. Growth and development history
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 History of her growth development was normal or similar as his peers until now.
f. Immunization history
Were as follow : BCG, DPT 3 times, hepatitis B 4 times, measles once.
Conclusion: immunization status were not according to health ministry immunization
programme.
g. Basic needs history
Stimulation, parenting, and caring was enough.
h. Family socio-economic condition
Midle socioeconomic level, patient has health insurance.
History during admission until determination as case
Two day of hospitalization 2’
Patient was complained of pale, limp, fever, and bruises were visible on the right leg.
Physical examination revealed moderately ill and alert. Pulse rate was 140-150 beats/minute, regular
with good pulse quality. Respiratory rate was 28-30 times/minute, regular, highest temperature was
38.3oC, pain score (FLACC) was 2 (mild), fall risk (Humpty-Dumpty) was 13 (high risk to fall).
Conjunctiva, lips and tongue mucosa, palm, and foot were pale. Multiple lymph nodes enlargement
were palpable in right and left submandibular, supraclavicuar, and inguinal region were palpable, with a
diameter of 1.5-2 centimeters (cm), firm, non-tender, and fixed. Cardiac auscultation revealed innocent
murmur throughout the ostium, grade III/6, without spreading. The liver was palpable 2 cm below the
processus xiphoideus and 4 cm below the costal arch, with sharp edges, soft consistency, smooth
surfaces, and painless; spleen was not palpable. No palpable testicular mass. There were bruises in the
right leg with diameter 1.5 centimeters (cm) and multiple petechiae on left auricle, forehead, abdomen,
and both leg. Based on anthropometric status, patient’s weight was: 11 kg, height: 92.5 cm, ideal
weight: 13.5 kg, mid-upper arm circumference (MUAC): 12.8 cm, standard MUAC: 16.2 cm, head
circumference: 49.5 cm, nutritional status based on MUAC was 79% (moderate malnutrition).
Complete blood count revealed : leukocytosis 58.09 K/µL with nutrophenia 0.27, anaemia with hb was
2.68 g/dL (MCV 87.59 fL; MCH 27.13 pg; MCHC 30.97 g/dL), trombocytopenia with platelet level
was 6.22 K/µL. Procalcitonin 0.20ng/mL. Patient was diagnosed with febrile neutropenia (D70.9),
severe anemia (D64.9) and severe thrombocytopenia (D69.6) et causa acute lymphoblastic
leukemia (L2) (C91.0), and moderate malnutrition (E44.0). Patient was planned for admission, fluid
requirement 1050 ml/day fulfilled by D5½NS infusion 16 macro drip/minutes, Calori requirement 1350
kcal/day, protein requirement 20.25 g/day (given as high-density formula 7 x 200ml), 1 L/minute of
nasal canule. Paracetamol 1 tea spoonwhen axilla temperature was ≥ 38oC repeated every four hours
and combined with warm compress, PRC transfusion 235 ml as given gradually which were given with
interval 24 hours among PRC transfusions, furosemide 1 mg/kg intravenous as pre-medication of PRC
tranfussion, thrombocyte concentrate (TC) transfusion 4 TC blood bag, and planned for CBC evaluation
three days after transfusion and urine analysis. Monitoring vital signs, transfusion reaction, body
weight, and food intake.
IV. PHYSICAL EXAMINATION (Objective) on June 15th, 2018
a. Present Status 2’
general condition moderatelly ill, compos mentis, blood pressure: 90/60mmHg (50-90th
percentile), pulse rate 130 times/minutes, regular, sufficient volume, respiratory rate 28
times/minutes, regular, oxygen saturation 98% in room air, axila temperature 38.3°C, pain scale
(FLACC): 2.
b. Status general
Head : normochepaly
Eye : pale conjunctiva, no icteric sclera, no subconjunctival bleeding
Ear, Nose, Throat: no bleeding, pharynx and tonsil no hyperemia
Mouth : pale on lips, no petechiae
Neck : multiple enlargement of submandibular and supraclavicular lymph nodes
with a diameter of 1.5-2 cm, firm, non-tender, and fixed.
Chest
Cardiac :
Inspection : no visible precordial bulging and ictus cordis
Palpation : ictus cordis in apex, without thrill, LV lift and RV heave was not felt.
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 Auscultation : normal heart sounds, regular, M1>T1, A2>P2, innocent murmur on all the
ostium, grade III/6, without spreading, no gallop
Lung : normal
Abdominal
Inspection : visible distention, superficial vein was not appeared.
Palpation : liver was palpable 2 cm below xiphoid processus and 4 cm below the costal
arch, sharp edges, soft consistency, smooth surfaces, and painless; spleen was
not palpable
Percusion : tympanic, shifting dullness was not found
Limbs : bruises in right leg with diameter 1.5-2 cm, firm, non-tender, and fixed
Genital : testes no enlargement
c. Neurological examination of four limbs within normal limit.
d. Pubertal status : tanner stage G1P1
e. Anthropometic status (based on CDC-2000)
Weight, weight for age : 11 kg (hepar enlargement), z-score -2 (normal)
Height, height for age : z-score below -1 (normal)
Weight for height : z-score below -2 (wasted)
MUAC : 12.8 cm
Standard MUAC : 16.2 cm
Nutritional status (MUAC): 79% (moderate malnutrition)
f. Developmental status
Kuesioner Pra Skrining Perkembangan (KPSP) score 10  development appropriate with age
Denver II score showed untesteable,
PedsQL score 44.4%  The quality of life of patients is currently low.
IV.DIAGNOSTIC 1’
Febrile neutropenia (D70.9), severe anemia (D64.9) and severe thrombocytopenia (D69.6) et causa
acute lymphoblastic leukemia (L2) (C91.0), and moderate malnutrition (E44.0).

Several problems that search through evidence based practice

1. In children with ALL, how to predict complications of febrile neutropenia?
2. In children with ALL, what are the risk factor of ALL?
3. In children with ALL, is delayed time to treatment compared to on time to treatment affect the
survival rate?
4. In children with undernutrition, how is the outcome of ALL?
5. In children with ALL, how is the quality of life of children with ALL?
V.PLANNING 2’
a. Emergency management
- Oxygenation 1 L/minute of nasal cannulae.
- PRC transfussion 235ml is given gradually (1st PRC 35ml, 2nd PRC 55ml, 3rd PRC 65ml, 4th
PRC 80ml) which was given with interval 24 hours among PRC transfusions, furosemide 1
mg/kg intravenous equivalent to 10 mg as pre-medication of PRC transfusion.
- TC transfussion 4 TC blood bag.
b. Planning diagnosis
- CBC count test will be repeated 3 day later.
- Urine analysis, to invetigate the etiology of febril neutropenia
- Chest anterior/posterior x-ray, to investigate the risk stage of ALL
- Liver functions, kidney functions, and electrolyte will be performed before start
chemotherapy and repeated every 2 weeks during chemotherapy
- BMA will be evaluated after completion of induction phase chemotherapy.
c. Planning of theraphy
1. Febrile neutropenia
Paracetamol 10 mg/kg oral equivalent to 110 mg (1 tsp) when axillary temperature ≥ 38oC
repeated every four hours and combine with warm compress.
2. Chemotherapy
According to Indonesian childhood ALL-2013 protocol.
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 d. Pediatric nutrition care
- Nutritional assessment: moderate malnutrition
- Nutritional requirement: energy requirement according to recommended dietary allowances
(RDA). Energy requirement 1350 kkal/day, protein requirement 20.25 g/day, fluid
requirement 1050 ml/day.
- Nutritional route: oral.
- Nutritional selection: is given rice porridge and side dishes, one portion every 8 hours with
a snack every 12 hours.
- Nutritional monitoring: intake, vomiting, diarrhea, weight gain.
e. Planning monitoring
- Closed monitoring during and after blood transfussion.
- Vital sign and seizure were observed intensively until thrombocytopenia improving.
- The role of parents is to maintain nutritional status of patients and to achieve optimal gowth
with Denver II examinations periodically.
- Compliance in chemotherapy and monitoring of short-term and long-term side effects of
chemotherapy.
VI. FOLLOW-UP 2.5’
After 7 days follow-up, patient not complaining of pale and fever. Good daily intake. Defecate and
urinate as usual. Present status showed normal condition. The liver was palpable 2 cm below the
processus xiphoideus and 4 cm below the costal arch, sharp edges, soft consistency, painless.
Laboratory evaluation: leukocyte 5.75 K/uL (absolute neutrophil 0.11 K/uL); hemoglobin 9.21
g/dL; platelet 103.79 K/uL. Patient diagnosed Febrile neutropenia (D70.9), severe anemia (D64.9),
and severe thrombocytopenia (D69.6) et causa ALL (L2) high risk induction phase 1 st week
(C91.0), moderate malnutrition (E44.0). Patient treated with total caloric 111% RDA, cefotaxime
stop, metotrexate chemotherapy 12 mg (intratecal), dexamethasone oral 6 mg/BSA (increased
gradually) oral until August 9tt,2018, next chemotheraphy plan: vincristine 1.5 mg/BSA
intravenous. If vital signs good and no side effects of chemotherapy, plans to do outpatient care.
VII. Communication, information and education plan
a. The disease and management
1. Patient with febrile neutropenia with normal limit of procalsitonin level therefore CBC
will be evaluated 3 days later. Patient & parents should more aware about healthy
lifestyle such as wash their hand routinely, use face-mask, and maintain family hygiene.
2. Severe thrombocytopenia can lead to ICH. Severe anemia can lead to tachypnea.
3. Patient needs TC and PRC transfusion due to severe thrombocytopenia and anemia.
4. Leukemia is not contagious disease so patient can still interact with his friends and
family.
5. Leukemia management is chemotherapy routinely according to the protocol.
b. The side effect of transfusion
Fever, chills, tachypnea, hypotension, tachycardia, loss of consciousness, urticarial, shock
c. The side effect of chemotherapy
Hair loss, mouth sores, loss of appetite, diarrhea, nausea and vomiting
d. Vaccination
It is generally recommended that vaccines should not be given during chemotherapy
treatment.
e. Long-term prognosis
Acute lymphoblastic leukemia is a chronic disease with a poor prognosis.
f. Psychosocial problems and quality of life
Patient needs PedsQL inspection at least every six months to assess quality of life and the
possibility of psychosocial disorders.

VIII. PROGNOSIS
a. Ad vitam : dubius ad malam
b. Ad functionam : dubius ad malam
c. Ad sanactionam : dubius ad malam
Estimasi total waktu 15’
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