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from a medical ambulatory (hospital) patient’s record No. 160751
EXTRACT
To Whom It May Concern
1.Last name,first name, father's name of the patient: Rybalko Mykola Romanovych
2.Date of birth July 29, 2011
3. Place of patient’s residence: 31 Matrosova street, Tsiurupynsk city, Tsiurupynsk district.
4. Place of employment (position) Kindergarten No. 4
5. Dates: admission to ambulatory policlinic establishment: June 01, 2014
discharged: continues treatment
Department: hematological Type of bed: hematological
6. Complete diagnosis: Acute lymphoblastic leukemia, common-variant, L1 by functional abdominal pain.
Complaints of fever for several days, the absence of catarrhal symptoms and complaints, changes in the blood cell count, anemia, leukopenia.
Disease anamnesis – he is ill for several weeks – has had cough, nasal catarrh, fever without catarrhal symptoms for three days, pale skin; has been examined by the district pediatrician, received symptomatic treatment. Blood cell count: HB 88, leucocytes -1, 3 thousand, lymphocytes 92%, mononuclear cells 2%, thoracic organs roentgenofluorography radiographs – without pathological findings, examined by otorhynolaryngologist, pediatrician - without pathological findings. According to information provided by mother he was ill with highly dangerous virus infection 2 weeks earlier, got antibiotic therapy Azymed, symptomatic treatment.
Patient's condition on admission OBJECTIVELY
Temperature is 36.9, breathing rate is 24 per 1 min. Pulse frequency is 123 for 1 min. The child's state of moderate severity. Body weight 19,7kg (75 percentiles) Body length: 106cm (75 percentiles)
The physical development of the child coincides his age. Consciousness is clear. The response to the examination is adequate. The condition in bed is active. Child has proportional body; nutrition is satisfactory. Skin and visible mucosae are of clear. Subcutaneous fat is developed moderately and evenly. The thickness of subcutaneous fat layer in the navel area is 1.0 cm. The swelling, welts are absent. Lymph nodes are palpable on the left side of neck of size 0.6 cm, they are soft, elastic, painless, are easily displaced by palpation between themselves and adjacent telas, are not glomerated. There is the asymmetry of the neck due to soft telas. Oropharynx: hyperemia, swelling and accretion are absent. Tonsils are not hypertrophic, do not act outside the brackets, are not hyperaemic. Muscles are developed satisfactorily. Muscle tone and strength are according to age. Muscle palpation is painless. Osteoarticular system is without deformation. Movement in joints is without restrictions. Head is of normal shape. Thorax is of normal shape; deformations, asymmetry, curvatures are absent. Epigastric angle is oblique. The spine is not distorted. Dysembryogenic stigmas are not found. Nasal breathing is not difficult. Discharges from the nose are absent. Voice is ringing. Breathing is rhythmic. Both halves of the thoracic cage are involved to the act of breathing. Breathlessness is absent. Chest is pliable, painless during palpation. Harsh breathing during the percussion of lungs is defined, the rattlings are absent. Activity of the heart is rhythmic, cardiac sounds are sonorous. Systolic murmur is not defined. Visible pulsation of the neck, limbs, temporal artery are not defined. Radial artery pulse is rhythmic of average filling. Pulse in the femoral artery is determined. Lips are pink and moist, mucous membrane of the mouth is clean, pink, moist; hemorrhages, aphthaes, morning wounds, Filatov spots are not defined.
Tongue is pink. Abdomen is symmetrical, is involved in breathing. Visible peristalsis of intestinal canal is not observed. The veins of the anterior abdomen wall are not extended. Abdomen is available for superficial and deep palpation. Palpation of the abdomen is painless. The lower edge of the liver is painless, soft, flexible, smooth, stands for 1 cm from the costal arch. Lien is palpable. Stool is regular. Urination is free. Urine color is straw-yellow. The genital organs are developed by male type. Secondary sexual characteristics are absent. Meningeal symptoms (stiff neck, Kernig symptom, Brudzynskyi upper and lower symptoms) are absent. Eyes are clean, eyelids are without swelling. The photophobia and tearing is not observed. The child sees, hears, understands the language addressed to him. Coordination of movements is not damaged. Conversation is correct.
DIAGNOSTIC STUDIES
June 02, 2014 hematocrit (Ht): Ht 36.
June 02, 2014 Complete blood cell count: Hb 102 g/l; erythrocytes 3.2 1012/l; color index 0.95; reticulocytes 14%0; platelets 188 g/l; leukocytes 1.4 g/l; Erythrocyte sedimentation rate 10 mm/ h; stab 0%; segmentonuclear 1%, eosinophils 0%; lymphocytes 96%; monocytes 3%; poikilocytosis inconspicuousglucose 3.6 mmol/l.
June 04, 2014 Complete blood count: Hb 105 g/l; erythrocytes 3.3 1012/l; color index 0.97; platelets 132 g/l; leukocytes 3.5 g/l; Erythrocyte sedimentation rate 8 mm/h; neutrophils: stab 0%; segmentonuclear 0%, eosinophils 0%; lymphocytes 99%; monocytes 1%; anisocytosis inconspicuous glucose 3.6 mmol/l.
June 02, 2014 Blood counts - indicators of coagulation: prothrombin ratio 1.12; prothrombin time 13 sec.; activated partial thromboplastin time 40 sec.; plasma fibrinogen 2.88 g/l; 02/06/2014, Soluble fibrin complex -,
June 02, 2014 blood alpha-amilase 31.9 mg / ml * h.
June 02, 2014 Biochemical blood analysis (protein metabolism): total protein 67.0 g/l; albumin 46.0 g/l; urea 4.3 mmol/l; creatinine 68.4 mcmol/l (ionogram): K 4.69 mmol/l; Na 138 mmol/l; Ca 2.54 mmol/l; Cl 100 mmol/l (Liver function tests): lip. 28 units.; total bilirubin 13.6 mcmol/l; direct bilirubin 1.5 mmol/l; indirect bilirubin 19.1 mcmol/l; alanine aminotransferase 1.5 mcmol/mL*h; thymol turbidity test 2.6 units.
June 02, 2014 blood type A (II); Rhesus Rh (+) positive.
June 02, 2014 Fe 17,8 mmol/l; iron-binding capacity 42.7 mcmol / l; unsaturated iron-binding capacity 24.9 mcmol/l, Fe 41,7%.
June 02, 2014 Enzyme Multiplied Immunoassay lg G,Ig G M: Enzyme Multiplied Immunoassay IgG negative, Enzyme Multiplied Immunoassay Cytomegalov. IgM negative; Enzyme Multiplied Immunoassay Herpes viridae IgG negative; Enzyme Multiplied Immunoassay Herpes viridae IgM Negative; Enzyme Multiplied Immunoassay Toxoplazm.gondii IgG negative; Enzyme Multiplied Immunoassay Toxoplazm.gondii IdM negative.
June 02, 2014 Clinical Urine Analysis: amount 70.0 ml; straw-yellow color; transparent; specific gravity 1005; protein -; Glucose -; leucocytes 0-1; epithelium: pavement, singular; transitional, mucous: fibrous inconspicuous.
June 02, 2014 Scraping analysis of enterobiosis: helminth eggs negative. (-).
June 02, 2014 Feces analysis (coprogram): Form unformed; soft consistence; brown color; digested vegetable fiber singular, not digested vegetable fiber singular; Fat neutral has not been found, sour fat is inconspicuous; apicomplexans -; helminth eggs are not found.
June 03, 2014 Bone marrow aspirates analysis: No. 39 amount of myelocariocytes 6900; amount of megakaryocytes has not been found; blasts that are not amenable to morphologic differentiation 68; elements of lymphopoiesis: lymphocytes 32; mitosis elements of white sprout. 1:500.
June 04, 2014 Analysis of cerebrospinal fluid: physically: amount 1,2, color white; transparency transparent; protein 0.03 g / l; Nonne-Apelt reaction -; Pandi reaction-; chlorides 111 mmol /l; glucose 3.5 mmol/l; cytosis 1 cells in 1 mcl (1 lymphocyte), erythrocyte single in medication.
June 02, 2014 Microflora investigation: material oropharynx, nose; Staphylococcus epidermidis is emphasized; sensitivity Amikacin-30 - sensitive (25); Vancomycin- 30 sensitive (17); Oxacillin-1 - sensitive (20); Cefazolin-30 - sensitive (25); Cefepime-30 - sensitive (20); Ceftriaxone-30 - sensitive (21); Cefuroxime-30 - sensitive (28); Ciprofloxacin-5 - sensitive (10); 2 Klebsiella pneumonia is emphasized; sensitivity 2 Amikacin-30-sensitive (18); Ampicillin-10 - sensitive (32); Meropenem-30 - sensitive (27); Cefepime-30 - sensitive (25); Cefotaxime 30 - sensitive (24), Ceftazidime-30 - sensitive (30), Cefuroxime-30 - sensitive (28); Ciprofloxacin-5 - sensitive (26);
June 05, 2014 Doppler Echocardiography Acuson CV70: aorta 18 mm; left atrium 19 mm; pulmonary artery 16 mm; left ventricle 28 mm; left ventricle posterior wall 5 mm; interventricular septum 5 mm; Fractional release 70%; maximum angle of pulmonary artery 7 millimetres of mercury, maximum angle of aorta. 5 millimetre of mercury; mitral valve normal, tricuspid valve normal, chambers of the heart are not expanded. The thickness of the myocardium is normal. Partitions have been tracked throughout. Course of major vessels is correct. The function of the valves is not broken. Blood flow in the abdominal aorta is pulsating. Driving myocardial activity is preserved; CONCLUSION Echopathology has not been found.
June 02, 2014 Electrocardiography: heart rate 158; conclusion - sinus rhythm; normal position of electrical axis of heart, tachycardia;
May 31, 2014 Thoracic organs roentgenofluorography: effective dose equivalent (mSv) 0.05; Lung fields are without visible pathological shadows; heavy compacted roots; heart size and shape are within age norms.
June 02, 2014 Ultrasound investigation of abdominal cavity and kidneys: liver: a clear outline; right hepatic lobe is 105 mm; left hepatic lobes is 54 mm; echostructure - smooth contour, homogeneous structure, average echogenicity, ordinary sound conductivity; gallbladder: length 72 mm; width 14 mm; form creases of the body; walls are not thickened; anechoic content; bile duct is not changed; pancreas: head 12 mm; body 10 mm; tail 12 mm; smooth contour; duct is not change, homogeneous echostructure; spleen: length 80 mm; width 38 mm; homogeneous echostructure, kidneys: right kidney: the default location; length 82 mm; width 35 mm; echostructure is not changed; left kidney: the default location; length 84 mm; width 35 mm; echostructure is not changed; conclusion: Echopathology has not been found.
Reference Laboratory Result OHMATDET (by phone) - acute lymphoblastic leukemia, common -
variant
No. 160751
PERFORMED TREATMENT
1. Ward regimen, 2. Nutritional care No. 5, Ceftriaxon 1000 – 2 times intravenous, Hroprynozyn ½ of tablet – 4 times, Aqua Maris - nasally.
Infusion therapy started in the form of infusion solutions, Prednizolon 43 mg intravenous, Asparkam 1 tablet – 2 times, Allopurinol ½ - 2 times, Almagel 1 teaspoon – 3 times per day.
Prescribed catheterization of central vein to conduct intensive care.
Mother cares for child. She does not need work incapacity certificate.
Quarantine is absent in department.
05/06/2014
Chief of Depertment Signature Redkina V.H.
Treating physician Signature Redkina V.H.
Seal:
Treating physician
Redkina V.H.
Seal:
Ukraine
Department of Health of Kherson Regional State Administration
Municipal Establishment Kherson Child Regional Clinical Hospital of
Kherson Regional Council
02009873