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Name of ministry, other executive authority organ, institution,
organization, managing present health care institution
.

Ministry of H
ealth of Ukraine
.

Name and location
(
full postal address
)
of health care institution
,
where this form is filled

Health care public utility
©
Kharkiv Municipal Children‱s Hospital

No
1


Kharkiv
, 61075,
Louis Pasteur st.

3

USREOU code
24660907


MEDICAL DOCUMENTATION

Primary accounting documentation form

No

027/о

APPROVED

Ministry of H
ealth of Ukraine order

14.02.2012
No

110

Inpatient (outpatient) hospitalization record No
2925

(
name and location of health care institution where this record is sent
)

1.

Patient‱s full name

Kharchenko Oleksii Oleksandrovych

2.

Birth date
05.03.2003

3.

Patient‱s place of residence
:
Kharkiv
,
Moskovsky district
,
Valentynivska st., 58
-
B,

212

fl.

4.

Work place

(
occupation
)

Secondary school No 5
6
,
7
b form

5.

(не читается)

a.

(не читается)

b.

In the inpatient department
:
admittance
14.07.16

d
ischarge or death
Up to present time

6.

Full diagnosis
(
main
disease, concurrent conditions

and complications
):

Acute myeloblastic l
eukemia
. М7

type according to FAB classification
. 1
-
st acute period
.

7.

Short anamnesis
,
diagnostic investigations
,
clinical course
,
conducted treatment
,
stage at referral
,
discharge

For the first time child admitted to the Hematology unit
14.07.16
with complaints on bone, joint, back,
leg aches
,
increasing of temperature up to
38°С

From case history



it is known, that child is sick for
1
week before the admittance
,

when
rise in body
temperature up to 38.3°C, and pain in the right hip joint observed. Then, aches in the left shoulder
have

arisen. Patient condition worsened, aches in joints

and

back increased, and
patient was directed to the
Hematology department of the Heal
th care public utility ©Kharkiv Municipal Children‱s Hospital No 16ª
with a diagnosis of hemorrhagic syndrome with
arthralgic
syndrome, acute
rhinopharyngitis
.

From life history



patient

suffered pneumonia in July 2015, frequent acute respiratory
infections,
06.11.2015 was taken to the dispensary registration in the TB dispensary with the next diagnosis:
Mycobacterium tuberculosis

infection, category 5, group 54.

Since 15.07.2016 0.35 mg Isoniazidum once a day therapy was prescribed.

At admittance
:
general condition of
moderate severity
,
severity is caused by
intoxication. Sluggish,
adynamic.
S
kin is pale.
Have regular
physique
, sufficient nutrition
.
No
pathology
has

been identified. Percussion
gives
clear lung sounds

above l
ungs
, hard breathing

in lung by auscultation
,
without

wheezing.
Heart t
ones
are
rhythmic. Abdomen
is
soft, painless,
and available

for palpation
in all
departments.
L
iver is palpated + 2
.0 cm

below the costal margin, spleen at the edge of the costal arch.

At inspection
:

In the
clinical blood assay

dated
18.07.2016


hemoglobin 95 g
/
l
,
erythrocytes 3.3х10
12
/
l
,
Colour index


0
.
85,
26
x
10
9
/l
,
leucocytes 5.
8
x
10
9
/
l
,
rod nuclear cells

5%,
segmentonuclear cells 36.
0%,
eosinophiles

3%,
lymphocytes

36%,
monocytes


7%,
blast cells
13%,
blood sedimentation rate


21

mm/h
.

Liver function tests

dated

15.07.2016:
GPT



0
.
4

mmol
/
l
,
alkaline phosphatase 6.
6
U
,
thymol test 1.
3
U
,
bilirubin


20
mmol
/
l
,
direct
5
mmol
/
l
,
indirect
15
mmol
/
l
.

Proteinogram

dated

15.07.16:
total protein


72
.4 g
/
l
,
albumines


5
8
%, αl


7
.4
%, α2


10.3
%, β


6.
6%, γ


17.
7%.

Blood urea

15.07.2016


4.
0
mmol
/
l
,
blood creatinine


106
mcmol/l
.

Acute phase indices

dated

15.07.2016
lycoprotheids 0.
494,
seromucoids


4.
8.

Blood type

da
ted

18.07.2016 В (III)
Rh positive
.

Cerebrospinal fluid

dated

28.07.2016


cytosis
3*10
6

l



Blood analysis for markers of virus hepatitis
В
and

С

(15.07.2016)
negative
.

Blood analysis for HIV

(19.07.2016)
negative

Ultrasound investigation

dated

18.07.2016


liver enlarged up to +1.
5
cm
,
parenchymal echogenicity
diffusely moderately raised, structure homogeneous, fine grained. Gall bladder is without pathology.
Pancreas has

equal contours. Spleen is moderately enlarged, echostructure

is unbroken. Conclusion


moderate hepatoelienal syndrome
.

Chest X
-
ray imaging

dated

18.07.2016
mSv


0.
02


no
focal and infiltrative changes are determined
on overview X
-
ray chest image.
On

the right in the basal part pulmonary image is enhanced
,

on
the left
it
is reinforced in the projection of the roots, roots
have weak structure, the right one have cords
. Heart


sharply shift
ed to the left. S
inuses are free,
diaphragm domes are
clear.

According to myelogram dated 18.07.2016 (Reference Laboratory o
f National Children's Specialized
Hospital "OKHMATDET" of the Centre of Children's Hematology and Bone Marrow Transplantation in
Kiev): taking into account identified peripheral blood blast cells, most likely there is a systemic neoplastic
blood disease, a
cute leukemia, or myelodysplastic syndrome. For the purpose of verification of the
diagnosis it is necessary to conduct morphological, immunological and cyto/molecular
-
genetic studies of
bone marrow. Therefore, bone marrow puncture of three points (sternal
, right and left iliac) was performed
again 25.07.2016: blast cells


67%, acute FAB
-
type myeloblastosis M 7.1 was finally diagnosed.

On 27.07.2016, chemotherapy course was initiated according to the scheme of induction AIE program
AML
-
BFM 2004. Transfusio
n of red blood cells

was carried out with the aim of
substitution. Antibiotic therapy
with Ceftriaxone, Braxone, T
azobactam.

According to the decision of Health care public utility ©Kharkiv Municipal Children‱s Hospital No 16ª
protoco
l №16 medical consultative board dated 28.07.2016 it is recommended to consider the child as
disabled from childhood in accordance with Section XVIII, item 2, subitem 2.34 (International
Classification of Diseases
-
10 code S.92.0) joint order of Ministry of

Health of Ukraine, Ministry of Labour
and Social Policy of Ukraine, Ministry of Finance of Ukraine dated 08.11.2001 No 454/471/516 “On
approval of the list of medical indications entitling to receive state social assistance for disabled children
under the

age of 16 years” for the period of 5 years.

For registration of documents parents must contact the clinic at the place of residence.

Chief

(неразборчиво)

Head of Haematology department

L.S. Bilousova

Attending physician

L.P. Marenych

01.08.2016


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