In the process of check-up

Epicrisis of medical history

Patient: Deripasko Platon Evgenievich

Date of birth: 30^th of October 2012

Place of birth: Yekaterinburg, Uchitely Street, H #18, Apt64.

Mother: Deripasko Irina Vasilievna, 15.01.1984, Tel: +7 (909)0040600;

Father: Deripasko Evgeny Grigorievich, 14.05.1982, Tel: +7(904)3838777.

Clinical diagnosis: Acute infantile lymphoblastic leukaemia,

Variant BIII – ALL, translocation t(9;11), with CNS affliction (neuroleukaemia), 1 very early combined (marrow + CNS) recurrence (C91.0).

Blood group O (I)αβ Rh(+) half CcDEe

Date of hospitalization in Department of paediatric oncology №2 RPCH №1, in the city of Yekaterinburg: 12.04.2013

Complaints: hyposthenic, moans, low appetite, pale.

Anamnesis of disease

Sick since 28.03.13. Occurrence of nasal congestion, mucous discharge from the nose and low-grade fever. Check-up by the paediatrician and diagnosis: ARVI, rhinitis, symptomatic therapy. No effect of therapy. The mother started noticing loss of baby’s appetite. The baby stopped eating the mix and seized gaining weight. The baby got hyposthenic, did not cry loud and moaned in the night. Last day the baby had stool with streaks of blood and mucus. On 11.04.13 the paediatrician checked the baby again due to complaints of persistent cold. A total medical check-up scheduled and FBC required. On 12.04.13 received FBC test results: Leucocytosis 488.7x109/l with lymphocytosis 78%, blasts 2:100, anaemia (haemoglobin 75g/l), platelet count 92x109/l. The Paediatrician recommended hospitalization at RPCH№1. The patient reached the hospital independently.

Anamnesis vitae

First born child born, 1x in-time delivery. Apparent cholestasis during pregnancy especially during the latter half (increased transaminase), the mother underwent treatment at MIW, was administered Essentiale. Delivery through C-section, due to no cervical dilatation under epidural anesthesia. The baby was born at 2740g and 49cm length. Apgar score 7/8 points. The baby immediately cried. Breast fed immediately. BCG, hepatitis B vaccination administered at the maternity center. Relieved from care on the fifth day. Umbilical wound not weeping. Breast feeding for 2 weeks with subsequent administration of Semilakt mix, because the baby did not gain weight. Psycho-physical growth in accordance with the age. Preventive vaccination in accordance with age, with the last vaccination on 13.03.13. Sicknesses suffered: ARVI, rhinitis, MMW infection (in IFA titre 1:100), MMW isolated in mother at the maternity home. Allergic anamnesis tranquil. No prior operations or injuries. The mother is 29 years of age with no chronic diseases and no professional hazards. The mother has higher education. The father is 30 years of age and is healthy. The father did not serve in the army (no conscription) and has no professional hazards. No tuberculosis, STDs or HIV as per parents’ accounts. Aggravated oncological anamnesis: grandfather and grandmother have c-r. Permanent residents of Yekaterinburg.

General check-up

Height 67. Wieght 6800. Body temperature 36.7. overall condition is crucial due to symptoms of intoxication, anemia and hyperleucocytosis. Consciousness is clear. State is passive, hyposthenic with lowered tonus. Body build is correct. Lowered feed. Skin is clear and pale. Visible mucous clean and pale. Sclera is clean and pale-pink. Subcutaneous fat evenly spread and mildly developed. Skin turgor pressure impaired. No pitting edema. No peripheral edema. Peripheral lymph nodes not enlarged.

Skull shape is correct. Fontanels: enlarged 2.0x1.5mm. Joint shape unchanged, soft tissue over the joint unchanged. No tenderness on palpation. All joint movements without pain. Lower limbs: unbent. Foot shape is normal. Muscle tone satisfactory. Muscle strength lowered.

Nasal breathing hard with mucous discharge. Nasal cavity filled with mucous. Oral pharynx has pale mucus. Pharynx: mucous clean, pink with no overlaps. Tonsils: no pathology seen. No change in external ear skin. Pressure on tragus painless.

Respiration rate 32; free breathing. No loss of breath. Chest form normal. Lungs borders normal according to age on both sides. Clear pulmonic sound during percussion. Auscultation of breath vesicular. No stertor audible.

Heart rate 160. Pulse is rhythmic and symmetric. No pulse deficiency. No visible vessel palpation. No visible pathologies in the cardiac zone. Apex beat at the typical place. Cardiac impulse is satisfactory during palpation. Cardiac borders normal according to age during percussion. Heart sounds are loud under auscultation. Heart noise is systolic.

Lowered appetite. The tongue is clean and moist. ABD is active in breathing and inflates. No pain during ABD palpation and is soft. The liver is extends by 6cm beyond the costal margin along the mammillary line. Spleen is enlarged +10cm. According to mother stool is greenish with mucus with no blood in stool today.

Fluent and painless urination. Urine is straw-yellow in colour and transparent. Male genitals formed correctly. Testis not enlarged.

In the process of check-up

13.04.2013 General blood test: Leucocytes – 604.49 10^9/l; Erythrocytes – 2.96 10^12/l;

Hb – 78 g/l; thrombocytes – 19 10^9/l; ESR – 6 mm/h.

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