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Re: PATIENT'S RECORD
Hi chi. Va^n
Chi. Va^n co' bie^'t hai o^ng ba\ Le^ Tho^'ng Nha^'t va\ NHU PHUONG MAI
na\y kho^ng? Tha^'y ba?o cu~ng ho.c MGU ra, cu\ng qua~ng Truong Gia Binh
(?)
Hai o^ng ba\ na\y co' con bi. be^.nh ma'u tra('ng ddang muo^'n gu+?i ddi
Ta^y
ddie^\u tri.
----------
> De : Tran Van Hai <tvhai@hanoi.vnd.net>
> A : Multiple recipients of list <vnsa-l@csd.uwm.edu>
> Objet : PATIENT'S RECORD
> Date : mercredi 25 juin 1997 05:56
>
> 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