Children’s City
Clinical Hospital No. 6
Hematology Unit
Dnipropetrovsk
Ministry of Health of Ukraine
Health Protection Department
of Dnipropetrovsk City Council
Municipal Facility
“Children’S City Clinical Hospital No. 6”
Code 01985127
49017, Dnipropetrovsk, Karavayeva st 68
_______________________________________________________________
Discharge summary from inpatient medical case #46
Patient: Anastasia
Yevgenievna Kotova, born on December 15, 1994, has being examined and taken
treatment in Hematology unit of Municipal Facility Children’s
City Clinical Hospital No. 6 since January 04, 2010 up to the present moment
January 08, 2010.
Address: Dnipropetrovsk, Babushkinskiy
district, Topol II, 2/4/1.
Clinical diagnosis:
acute myeloblastic leukemia, M2, I acute stage.
The patient is diagnosed according
to objective data and examination data: myelogram dated January 04, 2010: blast
cells 25%; complete blood count dated January 04, 2010: Hb – 80 g/L, RBC - 3.3 t/L,
PLT - 53 g/L, WBC – 28.0 g/L, ESR – 40 m/L, blasts – 30%, myelocytes – 9%, stab
– 4%, segmented – 28%, LYM – 21%, monocytes – 8%.
Swabs of marrow and
peripheral blood were examined in reference laboratory of State Specialized
Children’s Hospital Okhmatdet of the city of Kyiv, conclusion of Jan. 6, 2010 - acute myeloblastic leukemia, M2.
It is recommended to formalize with
medical consultation commission the receiving of welfare benefit till the girl
is 18 years old as being the disabled child according to Order #342 (Order #454
dated November 08, 2001) of Ministry of Health of Ukraine dated July
11, 2005, Chapter XVIII, Paragraph – 3, code by International Classification of
Diseases, 10th Edition – C92.
CHIEF OF DEPARTMENT [Signature]
ATTENDING DOCTOR [Signature]
S. A. Skotar
Deputy chief medical officer [Signature]
[SEAL]: Municipal Facility
“Children City Clinical Hospital
No. 6”
Code
01985127
Children’s City
Clinical Hospital No. 6
Hematology Unit
Dnipropetrovsk
Ministry of Health of Ukraine
Health Protection Department
of Dnipropetrovsk City Council
Municipal Facility
“Children’S City Clinical Hospital No. 6”
Code 01985127
49017, Dnipropetrovsk, Karavayeva st 68
_______________________________________________________________
Discharge summary from inpatient medical case #46
Patient: Anastasia
Yevgenievna Kotova, born on December 15, 1994, has been in Hematology unit of Municipal Facility Children’s City Clinical Hospital No. 6 since January 04,
2010 up to the present moment January 14, 2010.
Address: Dnipropetrovsk, Babushkinskiy
district, Topol II, 2/4/1.
Clinical diagnosis:
acute myeloblastic leukemia, M2, I acute stage.
Anamnesis:
hearing loop has been detected since November 2009. The patient was consulted
by ENT doctor and audiologist. On December 14, 2009 bilateral drum membrane
shunting was performed. In a week sanies appeared from acoustic meatuses. The
intoxication symptoms (weakness, low-grade fever), anemic syndrome, ‘shifting’
pains in the bones, right side facial numbness developed.
The patient was admitted to the
unit in a grave condition because of intoxication anemic syndrome and manifestations
of 7th cranial nerve (nervus facialis) paresis at right. She had mucopus from acoustic
meatuses.
Peripheral lymph nodes are not
enlarged.
Liver is up to + 2.0 cm lower costal
margin, spleen is located at the edge of costal margin.
Complete blood count
dated January 04, 2010: Hb – 80 g/L, RBC - 3.3 t/L, PLT - 53 g/L, ESR – 40 m/L,
WBC – 28.0 g/L, blasts – 30%, myelocytes – 9%, metamyelocytes – 2%, stab – 2%,
segmented – 28%, LYM – 21%, monocytes – 8%.
Myelogram
dated January 04, 2010: blast cells 25%.
Conclusion from the laboratory of
Oncological Hematological Center of State Specialized Children’s Hospital
Okhmatdet: acute myeloblastic leukemia, M2 (the conclusion is enclosed).
Examination of cerebrospinal fluid dated January 05, 2010:
cytosis – 1 cell in 1 μL.
Blood group:
A(II) Rh-positive blood.
Biochemical blood assay dated January 05, 2010: GPT 29 E/L, bilirubin 8
μmol/L, alkaline phosphatase 1.214 μkat/L, creatinin 88 μmol/L.
Ultrasonic examination of the visceral organs dated January 05,
2010: no pathology was detected.
Head CT dated January 06,
2010: bilateral mastoiditis, sphenoiditis.
Chest X-ray dated January 05, 2010: Cor et Pulmo within normal.
Neurologist consultation dated January 04, 2010: right facial nerve neuropathy.
ENT doctor consultation dated
January 04, 2010: bilateral exudates mastoiditis. Sphenoiditis. Bilateral
otitis media with effusion. Rinofluimucil nasally; okomistin into both ears and
nasally.
The patient receives antimicrobial therapy: cefepime, lyncomycinum.
Blood transfusions: packed red blood cells A(II)
Rh-positive
blood dated January 06, 2010, January 12, 2010; platelet concentrate – 250 ml
dated January 14, 2010.
Cytoreduction introductory stage starting since January 08, 2010: cytosar
40 mg/m2/day – 54 mg – IV – on January 08, 2010, January 09, 2010; tioguanine
(lanvis)
40
mg/m2/day – 54 mg – per os daily starting since January 08, 2010 up
to the present moment January 14, 2010.
The intoxication symptoms, mastoiditis and otitis signs became less
marked in dymanics.
Complete blood count
dated January 14, 2010: Hb – 92 g/L, RBC - 3.5 t/L, PLT - 21 g/L (before platelet
concentrate transfusion), WBC
– 10.3 g/L, myelocytes – 5%, stab – 2%, blasts – 29%, LYM – 39%, monocytes – 3%, ESR – 20 mm/g.
The discharge summary
was sent to the Head Children’s Hematologist of Ministry of Health of Ukraine, to S. B. Donskaya - Head of Children’s
Oncology and Hematology and Marrow
Transplantation Center
to receive recommendations for patient further management.
Children Hematologist of
Children City Clinical Hospital
No. 6 /signature/ S. A. Skotar
[SEAL]: Doctor Skotar Sergey Alekseevich]
District
Children’s Clinical Hospital of the city of Dnipropetrovsk
Computerized
Tomography and MRI Unit
49100, Kosmichna st 13, tel.: 713-63-08
Patient: A.Ye.
Kotova, 15 years old
Date: January 06, 2010 No. 2m0
Head spiral CT.
In sub- and supratentorial brain areas there are no
focal changes. Brain structures and fluid spaces are not deformed. Lesions of
the midline are not revealed. The sizes of fluid spaces are within normal. Pneumatization of mastoid
bones is absent. They are filled with the content with density of 4000 HU. Cavities
with diameter of 1 cm
are revealed there and a segment of periostitis on anterior surface at left is
detected. In basilar sinus the content with density of 4000 HU with horizontal leveling
is revealed (small amount).
Conclusion: bilateral mastoiditis. Sphenoiditis.
[SEAL]: Doctor [Signature]
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