MORTALITY REPORT

September 28th2019

2 YEARS 9 MONTHS OLD GIRL WITH AML M7 PRO CHEMOTHERAPY 2ND CYCLE, FEBRILE NEUTROPENIA,
BRONCHOPNEUMONIA, UTI (E. FAECIUM), NORMOCYTIC NORMOCHROMIC ANEMIA, DIAPER RASH, MUCOSITIS, CLINICALY
DOWN SYNDROME, END OF LIFE

Residenton Duty Saturday, September 28th 2019

On Duty I : Lusiana Aristianti, MD Inward Resident:
On Duty PICU : Andrew Hartono, MD Mira Mariana Ulfah, MD
On Duty NICU : Fajar Yuniftiadi, MD Suciati Jandraningrum, MD
On Duty RSND : Tyas Wuri Handayani, MD Martvera Susilawati, MD
On Duty PBRT 1 : Ari DwiRistianto, MD Monica Katherina Soegiarto, MD
On Duty PBRT 2 : Mira Mariana Ulfah , MD
On DutyED : Ima Sonia, MD Hematology Supervisor:
On Duty HCU : Akhmad Fauziannoor, MD
On Duty IV+ A : Muhammad Fathah, MD BambangSudarmanto, MD,SpA(K),MARS
On Duty IV+ B : Fanny Pritaningrum, MD
On Duty IV - : Ana Yunitasari, MD
On Duty V+ : Patricia Vanessa A, MD
On Duty ED junior : Selvi Destaria, MD
On Duty V-A : Laurentia Yustiana, MD
On Duty V-B : Aldila Vidya Ditha A, MD

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I. IDENTITY Neck : lymph nodes enlargement (-)
Name : HH Thorax : symmetric, retraction (-/-)
Date of birth/Age : November 17th, 2016/2 Years 9 Months Cor : heart sound I-II normal,murmur (-), gallop (-)
Charged Date : September 16 th,2019 Pulmo : Vesicular +/+ +/+
Death time : September 28th, 2019 Ronchi -/- -/-
Wheezing -/- -/-
ANAMNESIS Abdomen : distended, Abdominal sound (+) normal
Chief complaint: red spots on the skin Liver /spleen not palpable
Present Medical History: Extremities :
Patient was diagnosed with AML-M7 since August 2019 and had Warm +/+ +/+
1st chemotherapy one week before admission. Oedem -/- -/-
3 days before admission, patients complained fever, cough (+), Ptechiae +/+ +/+
ptekie (+) in both legs, gum bleeding (+), no complain about urinary and
defecation system. Because fever didn’t get better with antipyretic, and she Diagnosis :
was low intake, her mother brouhgt her to the Emergency Room. In the ER - AML M7 post chemotherapy 1st cycle
blood sample was taken for laboratory examination, the results was Hb Comorbid: Anemia and thrombocytopenia with bleeding
7,1, platelets 4000, leukocyte 400, and ANC was 0, she diagnosed with - Febrile neutropenic
febrile neutropenic, therefor she treated in the isolation room, got - Clinically Down syndrome
antibiotic, tranfussion, and underwent septic workup. - Electrolyte imbalance (Hiponatremia 130, Hypochloremia 97)

Past Medical History: Therapy:

AML-M7 since August 2019 O Infusion D5 ½ NS 240/10 ml/hour + NaCl 3% (3meq) 115 ml +
Family Medical History: KCl (2) 36 ml
There is no family with similar complaints O Inj. Cefepime 450 mg/8 hours (50 mg/kg/8 hours)
There is no family with history of malignancy diseases O Inj. Paracetamol 100 mg/4-6 hour (t ≥38ºC)

Physical Examination on September 16th, 2019

General Condition : looks pale Programs :
Consciousness : composmentis • Order PRC 150 cc
BW :8,7 kg, BH : 78 cm • Order TC 4 unit, 4 unit
HR: 100 x/mnt RR: 24x/mnt. • Consult to Microbiology division (anal and throat swab)
N: reg i/t adequate t : 38,4° C • Consult to ENT division
Eye : Anemic Conjungtival (+/+), upslanting eyes (+/+) • Chest X ray
Nose : flaring nostril (-), epistaxis (-) • Perform blood culture, routine urine, urine culture
Mouth : cyanosis (-),gum bleeding (+), gingiva hypertrophy (+) • Wait for the results of diffcount, peripheral blood morphology

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Further Diagnostic Examination
HEMATOLOGY STANDARD DENOMI Results Results Results Results
NATION (16/9/19) (18/9/19) (25/9/19) (27/9/19)
Hemoglobin 11.00 – 13.00 g/dL 7.1 9.9 8.5 10.9
Hematocrit 36-44 % 20.3 29.2 25.6 32.4
Erythrocytes 3 – 5.4 10^6/μL 2.76 3.69 3.23 4.03
MCH 23.00-31.00 pg 25.7 26.8 26.3 27
MCV 77-101 fL 73.6 79.1 79.3 80.4
MCHC 29.00-36.00 g/dL 35 33.9 33.2 33.6
Leucocytes 3.6 - 11 10^3/μL 0.4 0.8 0.5 0.7
ANC : 0/ul ANC : 30/ul ANC : 120/ul ANC : 120/ul
Platelets 150 - 400 10^3/μL 4 222 7 192
RDW 11.60 – 14.80 % 23.3 19.5 19.7 17.2
MPV 4.00 – 11.00 fl - 10.6 - 9.7

Diffcount Standar Denominatio 25/9/201 Peripheral 25/9/2019

Blood
d n 9 Morphology
Eosinophil 3–5 % 0 Erythrocytes Moderate anisocytosis (normocytes, microcytes),
Basophil 0-0 % 0 Moderate Poicilocytosis (ovalocytes, fragmentoctyes,
Bar 2–5 % 3 pear shape cells, target cells, schistocyte)
CLINICAL 25
Segment STANDARD
– 70 DENOMINATION
% 18 16/9/19 Platelets
25/9/19 Estimated
27/9/19platelet counts decreased, clumping (+),
CHEMISTRY 20 – 40
Lymphocyte % 70 fibrin (+), large shapes (+) dominated by normal forms
Blood glucose 80 – 160 Mg/dl Leukocytes
112 Estimated leukocytes number appeared decreased,
s
Ureum 15 -- 39 mg/dL 26 22 relative lymphocytosis (+), atypical mononuclear cell
Monocytes
Creatinine 4 –0,68 – 1,3 % mg/dL 4 0.4 0.4 5%, hypergranulated neutrophils (+)
Calcium 2.12 – 2.52 mmol/L 2.2 Impression
2.0 Pansitopenia
2.21 with normocytic normochromic anemia
Others AMC 5% because
Natrium 136 – 145 mmol/L 130 120 142of chemotherapy effects
Kalium 3.5 – 5.1 mmol/L 4.4 3.7 4.4
Chlorida 98 - 107 mmol/L 97 89 104
Uric acid 2.6 – 6.0 Mg/dl 2.1
Anorganic 2.4 – 5.1 Mg/dl 2.8
phosphat

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HsCRP 0 – 0.30 Mg/dl 19.71

ANAL SWAB 17/9/2019 IMMUNOSEROLOGY 25/9/2019 STANDARD

STAINING Procalcitonine 1.29 ng/ml <0.5 : low risk for sepsis
Gram staining 0.5 – 2 : need evaluation in 6-24
Diplococcus gram (+) +/POS hours
Bacil gram (+)
Urinalysis STANDARD +/POS 20/9/2019 Sperm 0–3 >2 : high
0.0 risk for severe sepsis
Bacil or shock septic
Color gram (-) +/POS Yellow Concentration 3 - 27 4.6
Leukocytes
Clarity 0-1 Clear
Pseudohyfa
Density +/POS
1.003 – 1.025 1.010
Yeast
pH cell +/POS
4.8 – 7.4 7
Protein 30 NEG
Reduction NEG NEG
Urobilinogen NEG NORMAL
Bilirubin NEG NEG Routine fexes STANDARD 17/9/2019 20/9/2019
Aseton NEG NEG Macroscopy
Nitrite NEG NEG Color Brown Brown
Epitel 0 – 40 0.1 Consistency Soft Soft watery
Epitel Tubulus 0–6 0.0 Microscopy
Leukocytes 0 – 20 1.1 Ascaris NEG NEG NEG
Erythrocytes 0 – 25 0.8 Ancylostoma NEG NEG NEG
Crystal 0 – 10 0.0 Trichiuris NEG NEG NEG
Cast 0 – 0.5 0.0 Oxyuris NEG NEG NEG
Coarse granule NEG NEG Cysts NEG NEG NEG
Fine granule NEG NEG Entamoeba
Hyaline cast 0 – 1.2 0.0 E. histolytica NEG NEG NEG
Epithelial cast NEG NEG E. coli NEG NEG NEG
Erythrocyte cast NEG NEG Food leftovers
Leukocyte cast NEG NEG Fats NEG +/POS 1 +/POS
Mucus 0 – 0.5 0.0 Carbohydrates NEG +/POS 1 NEG
Yeast Cell 0 – 25 0.2 Proteins NEG +/POS 1 NEG
Bacteria 0 – 100 2240.5 Meats NEG NEG NEG

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Vegetables NEG NEG NEG - Right hillar thickening, suspect of lymphadenopathy
Cells
Eryhtrocytes NEG NEG NEG ABDOMINAL X RAY 3 POSITION (ERECT-AP SUPINE-LLD)
Leukocytes NEG 0-1 NEG (18/9/19)
Epithel NEG NEG 0-1 Impression :
Others NEG NEG NEG - There are no necrotizing enterocolitis or pneumoperitoneum
Bacteria +/POS 1 +++/POS 3
Fungi NEG YEAST CELL YEAST CELL
+/POS 1 +/POS
HYFA +/POS
Benzidine NEG +/POS +/POS

CULTURE RESULTS
Throat swab 18/9/2019 : sterile
Feces 18/9/2019 : sterile
Anal swab 18/9/2019 : sterile
Blood 16/9/2019 : sterile
Urine 20/9/2019 : Enterococcus faecium
Antibiotics sensitive : Benyzlpenicillin,
Ampicillin, Gentamicin, Levofloxacin,
Quinupristin/ Dalfopristin, Linezolid,
Vancomycin, Tetracycline, Tigecycline
Antibiotics resistant : Streptomycin,
Erythromycin

CHEST X-RAY AP SEMIERECT 16/9/19

Impression :
- The heart is not enlarged
- Bronchopneumonia

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HISTORY OF THE DISEASE

Date/Time Sign and Symptoms, Further Exam Assessment Therapy, Program, Diet, Program
17-18/92019 Hematooncology Day : 1-3, BW : 8,7 kg, BH : 78 cm - AML M7 post chemotherapy O IVFD D10% 696/29 ml/hour
Day : 2-3 S: the patient was diagnosed with AML-M7 post 1st cycle D40% 16 ml + NaCl 3% (3meq) 37 ml
07.00 chemotherapy 1st cycle. Fever (+), gum bleeding - Febrile neutropenia (ANC 0) D10% 436 ml + KCl (2meq) 13 ml
(+), ptekie on body and legs, defecating and - Thrombocytopenia (4000) O Infusion of Aminofusin 5% 174/17 ml/hour
urinating within normal limit, hematemesis (+) - Anemia (7,1) O Inj. Cefepime 450 mg/8 hours (D1)
O: general conditions: irritable - Electrolytes imbalances O Inj. Paracetamol 100 mg/4-6 hour (t ≥38ºC)
HR : 134x/minute N : regular, adequate (Hyponatremia 130, O Inj. Tranexamic acid 125 mg/8 hours
RR : 24x/minute t : 39,2oC Hypochloremia 97) O Topical : Betadine gargle ue/12 hours
SpO2 : 99% - Obs. of Gastrointestinal O Nistatin 1 ml/12 hours
Eye : Anemic Conjungtival (+/+), bleeding
upslanting eyes (+/+) - Bronchopneumonia PROGRAM:
Nose : flaring nostril (-),epistaxis (-) - Clinicaly Down syndrome - Order PRC 150 cc
Mouth : cyanosis (-),gum bleeding (+), - Order TC 4 units, 4 units
gingival hypertrophy (+) - Wait for the results of Microbiology division
Neck : lymph nodes enlargement (-) - Wait for the results of urine culture, blood culture,
Thorax : symmetric, retraction (-/-) feses culture
Cor : heart sound I-II normal,murmur - Check routine blood, electrolytes, Ca, ANC, CRP, D-
(-), gallop (-) dimer, fibrinogen, PPT/PTTK, post transfusion
Pulmo : Vesicular +/+ +/+ - Diet : TPN
Ronchi -/- -/- - Consult to respirology division
Wheezing -/- -/-
Abdomen : distended, Abdominal sound (+)
normal
Liver / spleen not palpable
Extremities :
Warm +/+ +/+
Ptechiae +/+ +/+

Lab (16/9) :
Hb : 7,1
Ht : 20,3
L : 400 ANC : 0

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 Tr : 4.000
Na/K/Cl/Ca : 130/4,4/97/2,2

Chest X ray :
- Bronchopneumonia
- Right hillar thickening  suspect of
lymphadenopathy

Routine feces : Benzidine test (+)

Answer from ENT division

Assesment :
Currently there is no focal infection in ENT
division
Programme : therapy according to Pediatric
division

Answer from Respirology division

Assesment :
Bronchopneumonia
Programme :
- Inhalation 1 respule of Ventolin + 1
respule of Pulmicort per 8 hours
If TPN diet stop :
- Salbutamol 0,8 mg pulv/8 hours
- Methylprednisolone 0,8 mg pulv/8 hours
19-20/92019 Hematooncology Day : 4-5 , BW : 8,7 kg, BH : 78 cm - AML M7 post chemotherapy O IVFD D10% 696/29 ml/hour+ NaCl 3%
Day : 4-5 S: the patient was diagnosed with AML-M7 post 1st cycle (2meq) 24 ml+ KCl (2meq) 13 ml
08.30 chemotherapy 1st cycle. Intermitten fever (+), - Febrile neutropenia (ANC 30) O Infusion of Aminofusin 5% 174/17 ml/hour
gum bleeding (-), melena (+), watery stool (+) - Anemia (9,9) O Inj. Paracetamol 150 mg/4-6 hour (t ≥38ºC)
6x/24 hours, oral ulcer (+), - Obs. of Gastrointestinal O Inj. Cefepime 450 mg/8 hours (D3)
O: general conditions: ill appearance bleeding O Inj. Tranexamic acid 125 mg/8 hours
HR : 128x/minute N : regular, adequate Dd/ Colitis ulserative O Topical : Betadine gargle ue/12 hours
RR : 24x/minute t : 38oC Colitis neutropenia O Nistatin 1 ml/12 hours
SpO2 : 99% Typhlitis O Myconazole ue/8 hours

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Eye : Anemic Conjungtival (-/-), - Bronchopneumonia
upslanting eyes (+/+) - DIC Score 4 PROGRAM:
Nose : flaring nostril (-),epistaxis (-) - Clinicaly Down syndrome - Diet : TPN
Mouth : cyanosis (-),gum bleeding (-), - Mucositis - Wait for the results of blood culture (16/9), urine
gingival hypertrophy (+), oral - Diaper rash culture (16/9)
ulcer left buccal (+) - Inhalation 1 respule of Ventolin + 1 respule of
Neck : lymph nodes enlargement (-) Pulmicort per 8 hours
Thorax : symmetric, retraction (-/-) If TPN diet stop :
Cor : heart sound I-II normal,murmur - Salbutamol 0,8 mg pulv/8 hours
(-), gallop (-) - Methylprednisolone 0,8 mg pulv/8 hours
Pulmo : Vesicular +/+ +/+ - Transfusion of PRC 100 cc  delayed
Ronchi +/+ +/+ - Evaluation of general condition, vital signs, abdominal
Wheezing -/- -/- distention, shock
Abdomen : distended, Abdominal sound (+) - BC/D/12 hours
normal - Wait for the results of benzidine test (routine feces)
Liver / spleen not palpable - Consult to Dentistry division
Extremities :
Warm +/+ +/+
Ptechiae -/- -/-

Lab (18/9) :
Hb : 9,9
L : 800 ANC : 30
Tr : 222.000
Na/K/Cl/Ca : 143/3,9/108/2,15
CRP : 17,77
Fibrinogen : 44,28
D-dimer : 5020
PPT/PTTK : 1,2x/1,3x

BNO (18/9):
- There are no necrotizing enterocolitis or
pneumoperitoneum

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21-22/92019 Hematooncology Day : 6-7 , BW : 8,7 kg, BH : 78 cm - AML M7 post chemotherapy O IVFD D10% 696/29 ml/hour+ NaCl 3%
Day : 6-7 S: the patient was diagnosed with AML-M7 post 1st cycle (2meq) 24 ml+ KCl (2meq) 13 ml
04.00 chemotherapy 1st cycle. Intermitten fever (+), oral - Febrile neutropenia (ANC 30) O Infusion of Aminofusin 5% 174/17 ml/hour
ulcer (+), yellow coloured soft stool (+) - Anemia (9,9) O Inj. Cefepime 450 mg/8 hours (D5)
O: general conditions: ill appearance - Obs. of Gastrointestinal O Inj. Fluconazole 100 mg/12 hours (D1)
HR : 124x/minute N : regular, adequate bleeding (improvement) O Inj. Paracetamol 150 mg/4-6 hour (t ≥38ºC)
RR : 24x/minute t : 36,8oC Dd/ Colitis ulserative O Inj. Tranexamic acid 125 mg/8 hours
Eye : Anemic Conjungtival (-/-), Colitis neutropenia PO :
upslanting eyes (+/+) Typhlitis O Salbutamol 0,8 mg pulv/8 hours
Nose : flaring nostril (-),epistaxis (-) - Bronchopneumonia O Methylprednisolone 0,8 mg pulv/8 hours
Mouth : cyanosis (-),gum bleeding (-), - DIC Score 4 Topical :
oral ulcer left buccal (+) - Clinicaly Down syndrome O Betadine gargle ue/12 hours
Neck : lymph nodes enlargement (-) - Mucositis O Nistatin 1 ml/12 hours
Thorax : symmetric, retraction (-/-) - Diaper rash O Myconazole ue/8 hours
Cor : heart sound I-II normal,murmur
(-), gallop (-) PROGRAM:
Pulmo : Vesicular +/+ +/+ - Diet : tropic feeding : Pediasure 8x10 ml
Rales +/+ +/+ - Wait for the results of blood culture (16/9), urine
Ronchi -/- culture (16/9)
-/-Wheezing -/- -/- - Inhalation 1 respule of Ventolin + 1 respule of
Abdomen : distended, Abdominal sound (+) Pulmicort per 8 hours
normal - Evaluation of general condition, vital signs, abdominal
Liver / spleen not palpable distention, shock
Extremities : - BC/D/12 hours
Warm +/+ +/+ - Consult to Dentistry division
Ptechiae -/- -/-

Routine feces (20/9) :

Benzidine test (+)
23-24/92019 Hematooncology Day : 8-9 , BW : 8,7 kg, BH : 78 cm
Day : 8-9 S: the patient was diagnosed with AML-M7 post
06.00 chemotherapy 1st cycle. fever (+), oral ulcer (+),
yellow coloured soft stool (+) 3x/24 hours, blood
(-), mucous (-), cough (+) getting better
O: general conditions: ill appearance
- AML M7 post chemotherapy
1st cycle (9/9)
- Febrile neutropenia (ANC 30)
- Anemia (9,9)
- Bronchopneumonia
- Clinicaly Down syndrome
O IVFD D5 ½ NS 240/10 ml/hour
O Inj. Cefepime 450 mg/8 hours (D8)
O Inj. Fluconazole 100 mg/12 hours (D4)
O Inj. Paracetamol 150 mg/6 hour (t ≥38ºC)
O Inj. Gentamicin 60 mh/24 hours (D1)
PO :

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 HR : 110x/minute N : regular, adequate - Mucositis O Salbutamol 0,8 mg pulv/8 hours
RR : 22x/minute t : 38,1oC - Diaper rash (improvement) O Methylprednisolone 0,8 mg pulv/8 hours
Eye : Anemic Conjungtival (-/-), Topical :
upslanting eyes (+/+) O Betadine gargle ue/12 hours
Nose : flaring nostril (-),epistaxis (-) O Nistatin 1 ml/12 hours
Mouth : cyanosis (-),gum bleeding (-), O Myconazole ue/8 hours
oral ulcer left buccal (+)
Neck : lymph nodes enlargement (-) PROGRAM:
Thorax : symmetric, retraction (-/-) - Diet : Pediasure 4x100 ml, Rice porridge 3 x ½ portion
Cor : heart sound I-II normal,murmur - BC/D/12 hours
(-), gallop (-)
Pulmo : Vesicular +/+ +/+
Rales +/+ +/+
Ronchi -/-
-/-Wheezing -/- -/-
Abdomen : Abdominal sound (+) normal,
supel, Liver / spleen not palpable
Extremities :
Warm +/+ +/+
Ptechiae -/- -/-

Blood culture (16/9) : sterile

25/9/2019 Hematooncology Day : 10 , BW : 8,2 kg, BH : 81,5 - AML M7 post chemotherapy O IVFD D5 10% 240/10 ml/hour + NaCl 3%
Day : 10 cm 1st cycle (9/9) (2meq) 24 ml + KCl (2meq) 13 ml
06.00 S: the patient was diagnosed with AML-M7 post - Febrile neutropenic (ANC 30) O Inj. Cefepime 450 mg/8 hours (D9) 
chemotherapy 1st cycle. intermitten fever (+), - Normocytic normochromic Vancomycin
defecation (+) 1x/24 hours anemia (9,9) O Inj. Fluconazole 100 mg/12 hours (D5)
O: general conditions: irritable - Bronchopneumonia O Inj. Paracetamol 150 mg/6 hour (t ≥38ºC)
HR : 110x/minute N : regular, adequate - Clinicaly Down syndrome O Inj. Gentamicin 60 mh/24 hours (D2)
RR : 24x/minute t : 38,1oC - Mucositis (improvement) PO :
SpO2 : 98% - Diaper rash (improvement) O Salbutamol 0,8 mg pulv/8 hours
Eye : Anemic Conjungtival (-/-), - UTI (E. faecium) O Methylprednisolone 0,8 mg pulv/8 hours
upslanting eyes (+/+) - Post gastrointestinal bleeding Topical :
Nose : flaring nostril (-),epistaxis (-) O Betadine gargle ue/12 hours
Mouth : cyanosis (-),gum bleeding (-) O Nistatin 1 ml/12 hours

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 Neck : lymph nodes enlargement (-) O Myconazole ue/8 hours
Thorax : symmetric, retraction (-/-)
Cor : heart sound I-II normal,murmur PROGRAM:
(-), gallop (-) - Diet : Pediasure 4x100 ml, Rice porridge 3 x ½ portion
Pulmo : Vesicular +/+ +/+ - Check routine blood, blood glucose, diffcount, GDT,
Rales -/- -/- Quantitative CRP, Ur/Cr, Ca, electrolytes, uric acid,
Ronchi -/- anorganic phosphat
-/-Wheezing -/- -/- - Consult to PPRA division
Abdomen : Abdominal sound (+) normal,
supel, Liver / spleen not palpable
Extremities :
Warm +/+ +/+
Ptechiae -/- -/-

Urine culture (16/9) : E. faecium

Answer from PPRA division
Assesment :
- AML M7
- Bronchopneumonia
- Febrile neutropenia
- UTI (Enterococcus faecium)
Programme :
- Inj. Vancomycin 220 mg (25 mg/kg) initial
dose  175 mg/8 hours (20 mg/kg/times)
diluting in NaCl 0,9% 50 ml, in 90
minutes
- Continue Gentamicin injection
- Stop Cefepime injection
26-27/92019 Hematooncology Day : 11-12 , BW : 8,2 kg, BH : 78 - AML M7 pro chemotherapy O IVFD D5 10% 240/10 ml/hour + NaCl 3%
Day : 11-12 cm 2nd cycle (28/9) (2meq) 67 ml + KCl (2meq) 34 ml
06.50 S: the patient was diagnosed with AML-M7 post - Febrile neutropenic (ANC 30) O NaCl 0,9% correction 200ml/24 hours
chemotherapy 1st cycle. intermitten fever (+), - Normocytic normochromic O Inj. Vancomycin 175 mg/8 hours (D2) diluting
defecating (+) 1x/24 hours anemia (8,5) in NaCl 0,9% 50 ml, in 90 minutes
O: general conditions: irritable, VAS 4 - Bronchopneumonia O Inj. Fluconazole 100 mg/12 hours (D6)
HR : 109x/minute N : regular, adequate (improvement) O Inj. Paracetamol 150 mg/6 hour (t ≥38ºC)

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 RR : 22x/minute t : 37oC - UTI (E. faecium) O Inj. Gentamicin 60 mh/24 hours (D3)
SpO2 : 98% - Clinicaly Down syndrome PO :
Eye : Anemic Conjungtival (-/-), - Diaper rash O Salbutamol 0,8 mg pulv/8 hours
upslanting eyes (+/+) - Electrolytes imbalances O Methylprednisolone 0,8 mg pulv/8 hours
Nose : flaring nostril (-),epistaxis (-) (Hyponatremi 120, Topical :
Mouth : cyanosis (-),gum bleeding (-), Hipochloremi 89) O Betadine gargle ue/12 hours
oral ulcer (+) diminished O Nistatin 1 ml/12 hours
Neck : lymph nodes enlargement (-) O Myconazole ue/8 hours
Thorax : symmetric, retraction (-/-) O Durogesic patch 12,5 mg/3 hours
Cor : heart sound I-II normal,murmur
(-), gallop (-) PROGRAM:
Pulmo : Vesicular +/+ +/+ - Diet : Pediasure 4x100 ml, Rice porridge 3 x ½ portion
Rales -/- -/- - Check electrolytes, Ca post correction
Ronchi -/- - MST 5 mg/4 hours
-/-Wheezing -/- -/- Chemotherapy drugs 2nd cycle :
Abdomen : distended, Abdominal sound (+) - Donorubicin 21,5 mg intravenous
normal - Cytarabine 43 mg/12 hours intravenous
Liver / spleen not palpable - Etoposide 43 mg intravenous
Extremities : - Cytarabin 50 mg intratechal
Warm +/+ +/+ - Ondancentron 2 mg intravenous
Ptechiae -/- -/-

Lab (25/9) :
Hb : 8,5
L : 500 ANC : 120
Tr : 7000
CRP : 19,71 GDS : 112
Ur/Cr : 22/0,4 uric acid : 2,1
Procalcitonine : 1,29 phosphat : 2,8
Na/K/Cl/Ca : 120/3,7/89/2,8
28/92019 Hematooncology Day : 13 , BW : 8,2 kg, BH : 78 cm - AML M7 pro chemotherapy O IVFD D5 ½ NS 240/10 ml/hour
Day : 13 S: the patient was diagnosed with AML-M7 post 2nd cycle O Inj. Vancomycin 175 mg/8 hours (D4) diluting
07.00 chemotherapy 1st cycle. Fluctuating fever (+), - Febrile neutropenia (ANC 30) in NaCl 0,9% 50 ml, in 90 minutes
fussy (+), cough (+) has diminished - Normocytic normochromic O Inj. Fluconazole 100 mg/12 hours (D8)
O: general conditions: awake anemia (8,5) O Inj. Paracetamol 100 mg/4 hour (analgetic)

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 HR : 110x/minute N : regular, adequate - Bronchopneumonia O Inj. Gentamicin 60 mh/24 hours (D5)
RR : 20x/minute t : 37,2oC (improvement) PO :
SpO2 : 98% VAS : 3 - UTI (E. faecium) O Salbutamol 0,8 mg pulv/8 hours
Eye : Anemic Conjungtival (-/-), - Clinicaly Down syndrome O Methylprednisolone 0,8 mg pulv/8 hours
upslanting eyes (+/+) - Diaper rash Topical :
Nose : flaring nostril (-),epistaxis (-) - Electrolytes imbalances O Betadine gargle ue/12 hours
Mouth : cyanosis (-),gum bleeding (-), - Retentio urine O Nistatin 1 ml/12 hours
oral ulcer (+) diminished O Myconazole ue/8 hours
Neck : lymph nodes enlargement (-) O Durogesic patch 12,5 mg/3 hours
Thorax : symmetric, retraction (-/-)
Cor : heart sound I-II normal,murmur PROGRAM:
(-), gallop (-) - Diet : Pediasure 4x100 ml, Rice porridge 3 x ½ portion
Pulmo : Vesicular +/+ +/+ - Evaluate pain scale
Rales -/- -/- - MST 5 mg/4 hours
Ronchi -/- - Lactulose 5 ml/24 hours
-/-Wheezing -/- -/- - DC insertion  failed
Abdomen : distended, Abdominal sound (+) Chemotherapy drugs 2nd cycle :
normal - Donorubicin 21,5 mg intravenous
Liver / spleen not palpable - Cytarabine 43 mg/12 hours intravenous
Extremities : - Etoposide 43 mg intravenous
Warm +/+ +/+ - Cytarabin 50 mg intratechal
Ptechiae -/- -/- - Ondancentron 2 mg intravenous

Lab (27/9) :
Hb : 10,9
Ht : 32,4
L : 700
Tr : 192.000
Na/K/Cl/Ca : 140/4,4/104/2,2
S: abdominal distention (+), defecating (-) since 2
07.20 days ago - Retentio urine - Urine catheter insertion  failed
O: general conditions: awake
HR : 110x/minute N : regular, adequate
RR : 30x/minute t : 36,9oC
Abdomen : mass at suprasymphisis regio, suspect

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 of vesica urinaria is full

S: abdominal distention (+), fever (-), urinating (+)

a little, defecating (-) since 2 days ago - AML M7 pro DPJP advice :
10.19 - Consult to Pediatric surgery for catheter
O: general conditions: awake chemotherapy 2nd cycle
HR : 130x/minute N : regular, adequate - Febrile neutropenia and rectal tube insertion  DC insertion
RR : 28x/minute t : 36,8oC - UTI done by pediatric surgeon
SpO2 : 94% - Retentio urine - BNO delayed
Abdomen : mass at suprasymphisis regio (+),
suspect of vesica urinaria is full
Distended, Abdominal sound (-), lien/spleen not
palpable

S: DC has already inserted by Pediatric surgery

division - AML M7 pro
11.00 - Continue chemotherapy
O: general conditions: awake chemotherapy 2nd cycle
HR : 132x/minute N : regular, adequate
RR : 30x/minute t : 37oC
Urine production : ± 300 cc

S: Anesthesy has already started for intratechal

intervention preparation. - Desaturation - O2 nasal canule
13.10 Fever (-), shortness of breath (-), desaturation (+) - Reposition
during ketamine injection  Saturation increase to normal
O: general conditions: somnolent on sedation - Continue injection intratechal cytarabine
HR : 101x/minute N : regular, adequate
RR : 10x/minute SpO2 : 75%

S: post cytarabine injection intratechal, clear CSF,

smooth flow (+), blood seeped out (-) - AML M7 on
O: general conditions: somnolent on sedation chemotherapy 2nd cycle
13.15 HR : 130x/minute N : regular, adequate - Observe general condition and vital signs
RR : 24x/minute SpO2 : 98%

S: post injection intratechal cytarabine in GA,

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 good condition post intervention
O: - AML M7 on
HR : 120x/minute chemotherapy 2nd cycle - Observe general condition and vital signs
Follow up by RR : spontan breathing adequately
anesthesia SpO2 : 100%
13.30
Response to tactil (+)

S: bradycardia, unconsciousness
O: general conditions: -
- Cardiac arrest
HR : - N : not palpable - CPR with VTP support  Inj. Adrenaline
RR : - SpO2 : - 2 ampoules  CPR  Asistole, maximal
Follow up by Eyes : midriatic pupil (+) pupil midriatic
Code blue team Mouth : cyanotic (+) - Patient was declared death at 14.40
14.20 Extremities : cold acral (+/+) - Family emotional support
ECG : asistole

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