PATIENT'S RECORD

[Tran Van Hai <tvhai@hanoi.vnd.net>]

INSTITUTE FOR PROTECTION            Hosp. Code:121935
OF CHILD HEALTH                 Date of admission: May 4th,1997

DEPARTMENT OF HEMATOLOGY
     AND ONCOLOGY

                     PATIENT'S  RECORD


Name    : LE  PHUONG  LIEN
Date of birth   : 11 years old
Sex     : Female
Nationality     : Vietnamese
Present address : No. 82, Quan Thanh Street, Ba Dinh District, Hanoi
-Vietnam
Father  : LE  THONG  NHAT       Age: 40
Occupation      : Professor of Hanoi University. Doctor of Chemistry
Mother  : NHU PHUONG MAI        Age: 41
Occupation      : Professor of Hanoi University of Technology. Doctor of
Math.

HISTORY OF GROWTH AND DEVELOPMENT

At birth        : First pregnancy of the mother
          Normal delivery
          Birth weight: 2 700 g
Number of children of family: 1
Physical growth and mental development: Normal
Vaccination     : Full of programme

HISTORY OF DISEASE

Six days before admission of hospital the child was suffering from:
        - Moderate fever
        - Tiredness
        - Pale
        - Hemorrhage on skin
Treatment before admission: Not any

PHYSICAL FINDINGS

1. General status       : Fever 38oC, Tiredness
          Weight: 32 kg,        Height: 134 cm
2. Skin and mucous      : Pale, some petechies and ecchymosis on trunk
and
extremities.
3. Muscle and skelete   : Normal
4. Lymphe nodles        : Enlarged submaxilar
5. Spleen       : Splenomegalia, 2 cm below costal
6. Liver        : Not enlarged
7. Respiratory system   : Normal
8. Cardio - vascular system     : Not findings of abnormal
9. Gastro - intestinal system   : Colite and melena
10. Uro - genital system        : Normal
11. CNS and mental status       : Normal
12. Other signs and symptoms: Not findings

LABORATORY EXAMINATION

Hemogramme at admission ( April 29th, 1997)
* Hemoglobin                    11g/100ml
* Hematocrit                    30%
* Erythrocytes                  3.750.000/mm3
* WBC                   13.700/mm3
   Neutrophil segment           14%
   Monocytes                    2%
* Lymphocytes           23%
* Lymphoblast                   61%  ()
* Platelet                      30.000/mm3  ()

- Myelogramme at admission ( May 4th, 1997)
Number of cells in bone marrow: Normal
Lymphoblast     : 82%
Lymphocyte      :   5%
Neutrophil segment      :   3%
Erythroblast    :   0%
Megacaryocyte   : No
Cerebro - Spinal Fluid  : Normal
Transaminaza - GOT      : 17.5 U/l
                       - GPT    : 42 U/l

CLINICAL DIAGNOSIS

Acute Lymphoblastic Leukemia (ALL)
Type:  L1 (after FAB Classification) with High Risk.
TREATMENT
1.Induction therapy
-Chemiotherapy:
        Vincristin 1.5mg, IV on May 4,11, 26
                             on June 2, 9, 16
        Adriamycine 30mg, IV on the same days with Vincristin
        Prednison 50mg, on May 4 . June 11th
- Leucomax (GM.CSF) on May 11 . 22
- Blood transfusion
- Antibiotic therapy
- Acid folic
2. CNS prophylaxie therapy
        Methotrexate 10mg intrathecal on May 4, 12, 26...
3. Follow up during induction therapy:
- On 4 th May, 1997
        Hb      : 90g/l
        Hematocrit      : 26%
        WBC     : 3.3 x 109 /l
                Neutrophil segment: 69%
                Monocyte        :  1%
                Lymphocyte      : 28%
                Lymphoblast     : 2%
        Platelet        : 30 x 109 /l
- On 6 th May 1997
        Hb      : 80g/l
        WBC     : 2.1 x 109 /l
                Neutrophil segment: 70%
                Lymphocyte      : 30%
                Lymphoblast     : 0%
        Platelet        : below 50 x 109 /l

- On 12 th May 1997
        Hb      : 80g/l
        WBC     : 0.98 x 109 /l
                Neutrophil segment: 64%
                Monocyte        :  4%
                Lymphocyte      : 32%
        Platelet        : 50 x 109 /l

- Stop of chemotherapy and GM.CSF therapy from May 11 . 22

- On 23 rd May 1997
                Hb      : 90g/l
                WBC     : 2.4 x 109 /l
                Neutrophil segment: 20%
                Monocyte        :  30%
                Lymphocyte: 50%
        Platelet        : 120 x 109 /l

- Continued chemotherapy by Vincristine IV
                                   Adriamycine  IV
                                 Methotrexat    IT

- On 31 st May 1997

        Hb      : 100g/l
        WBC     : 6.2 x 109 /l
                Neutrophil segment: 58%
               Monocyte        :  5%
                Lymphocyte: 37%
        Platelet        : 200 x 109 /l

- On 6 th June 1997
        Hb      : 100g/l
        Hematocrit      : 32%
        WBC     : 7.4 x 109 /l
                Stab    : 3%
                Neutrophil segment: 74%
                Monocyte        :  5%
                Lymphocyte: 18%
        Platelet        : 250 x 109 /l
        Reticulocyte    : Blood: 2%
                          Bone Marrow: 1.5%

Myelogramme:
        Number of cells in bone marrow: 42 x  109 /l
        Myelocyte       : 1%
        Metamyelocyte   : 3%
        Stab            : 6%
        Neutrophil Segment: 42%
        Lymphoblast     : 5%
        Lymphocyte      : 39%
        Erythroblast    : 4%
Clinical findings: Moderate anemia only, no clinical signs

4. Consolidation therapy will be from 18 June 1997 by L _ asparaginaza.


                    Hanoi, June 12 th 1997

Head Department
of Hematology and
Oncology                                                
(signed )
Prof. NGUYEN Cong Khanh                                


Physician
(signed)
Dr. Bui Ngoc Lan