【院所:中國醫藥⼤學附設醫院】 病歷號:0037245216 姓名:陳沛恩 年齡:4歲 床號:B6-18

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住院 1120924－
病歷 醫囑 ⻄藥 中藥 床位 護理 病程 評估 給藥 其他
現⾏ ⼩兒⾎液腫瘤
【中國醫藥⼤學附設醫院】 0037245216 陳沛恩1120924－
科
⾨診 【醫師:蘇旻昱 ⼩兒⾎液腫瘤科】
1120808－ 主診斷 Z51.11 來院接受抗腫瘤化學治療
急診 1120908
⼩兒⾎液腫瘤 次診斷 C91.00 急性淋巴芽球性⽩⾎病，未達到緩解
住院 科
次診斷
1120710－ 次診斷
檢查 1120723
檢驗 ⼩兒⾎液腫瘤 次診斷
科 次診斷
累積
1120626－ 選擇： 入院病歷記錄【蘇旻昱】
報告 1120702
⼩兒⾎液腫瘤 入院病歷記錄【蘇旻昱】
⼿術 科

1120530－ Basic data

會診
1120617 Age/Sex:3歲10⽉23天/female
⼩兒⾎液腫瘤 Occupation:nil Marital status:single
其他
科 Ethnic origin:閩南 Place of residence :台中市北屯區台中市北屯區⼤連路三段
16號8
1120423－
Source of information:family Referring physician:none
1120515
Travel history:nil
⼩兒⾎液腫瘤
Past history:
科
Chief Complaint
admitted for blincyto target therapy

Present Illness
This 3-year-10-month-old girl with history of Acute lymphoblastic leukemia, RB1
heterozygous deletion was admitted via out-patient department admitted for blincyto target
therapy.
According to patient and medical chart, patient had fever for 4 days with abdominal pain and
was admitted to our ward during 2023/2/2-2023/2/7, we provided antipyretic treatment and
fluid supplement. Labaratory data showed high TG and elevated ferritin, hemophagocytic
syndrome was suspected. However, since the patient's symptom relieved, she discharged
from our ward. On 2023/3/1, patient had fever up to 38.6°C for one day with abdominal pain,
thus came to our out-patient department for help. At that time, decreased activity, decreased
appetite and diarrhea once was noted. Physical examination showed abdominal distension
and hepatomegaly. Lab data showed normocytic anemia leukocytosis with 10.8 * g/dL, and
blasts： 3.5%. She started chemotherapy for acute B-cell lymphoblastic leukemia under
TPOG-ALL 2021 protocol treatment since 2023/3/6.
Induction I course was on 3/6-3/26. MRD on day 15 (3/20) was 6.987%, so we started the
course of Induction II-B (03/27-04/16). The chemotherapy was prescribed smoothly and the
patient tolrated it well. MRD on day 42 (4/18) was 4.726%. During last admission, we kept
the course of Early Intensification plus from the 8th-9th week (04/23-05/10), the
chemotherapy was prescribed smoothly and the patient tolrated it well. Spinal puncture and
Intraventricular reservoir chemotherapy was done on day 58 without any discomfort. During
her last admission 2023/07/10-2023/07/23, she suffered from neutropenic fever, therapy was
on hold and she received intrathecal injection of chemotherapy on 7/17. Her older brother
had coough without fever but she denied having any major discomfort recently.
This time, she was admitted to our ward for scheduled Blincyto target therapy.

=Oncology summary=revised on 20230925

1. Initial presentation ：
Fever up to 38.6'C for 1 day, with abdominal pain, decreased activity, decreased appetite,
blast detected(18.9%) in blood

2. Diagnosis ：
B cell acute lymphoblastic leukemia, Rb1 heterozgous mutation
CNS status： CNS-1

3. Disease extent ：
D15(03/20), MRD1 = 1.744 % -> HR; 6.9% by CMUH (by clonal IgG rearrangement); MRD
= 6.987% by 長庚 hospital
D44(04/18), MRD2 = 0.136% by NTUCH; MRD2 = 4.726% by 長庚 hospital
20230531, post-induction MRD = 0.258% by CGMH
20230717, before-consolidation wk7 for neutropenia MRD： negative

4. Treatment course ：
TPOG-ALL-2021 VHR induction therapy
Induction I (03/06-03/26)
Induction II-B (03/27-4/16)
Early intensification plus (EI＋) (4/27-5/10)
consolidation thrapy： 0601-0731
blincyto I ->0809-
blincyto II ->0925-

5. Treatment effect and side effect ：

Effect：
D15(03/20), MRD1 = 6.987% by 長庚 hospital; MRD1 = 1.744 % -> HR
D44(04/18), MRD2 = 4.726% by 長庚 hospital; MRD2 = 0.136% by NTUCH
20230531, post-induction MRD = 0.258% by CGMH
Post BiTE(I) MRD： negative

Side effect：
- Elevated Triglycerides： 386(03/16)

6. Ongoing problems and future plan：

- Keep TPOG very High risk protocol
- apply for Start Blincyto
- compare different MRD data
- monitor hypogammaglobulinemia

Past History & underlying disease

[過去史]
She was born to a G2P2A0 mother by spontaneous vaginal delivery after a gestational age of
39＋2
weeks with birth body weight of 3200gm.

Development History：
三歲⾄四歲
---會從樓梯的最後⼀階雙腳跳下
---會單腳站立⼀⾄數秒
---會畫圓形
---會念或唱⼀⾸完整的兒歌
---說畫時會正確地使⽤代名詞「你」「我」「他」。
---會⾃⼰去廁所尿尿
---會⾃⼰解開扣⼦和脫掉衣服

Feeding History： normal diet

Previous Illnesses/Hospitalizations/Surgeries： ALL s/p TPOG-ALL-2021 HR since
112/03/06
Allergies： No known allergy to food and medicine
Food allergy： denied
Drug allergy： denied
Contrast medium allergy： denied

疫苗Immunizations：

◎30個⽉：Hepatitis B (3), Diphtheria, tetanus, acellular pertussis, inactivated polio and

Haemophilus influenzae type b conjugate vaccine (4), Pneumococcal conjugate vaccine (13-
valent) 13
(3), Bacille Calmette-Gurin vaccine (1), Varicella (1), measles, mumps and rubella vaccine
(1),
Japanese encephalitis live chimeric vaccine (2), Hepatitis A vaccine (2), COVID vaccine
(Moderna,
2)

[Current Medication]
本院⽤藥(含中藥)：
⾨診⽇期 藥 品 名 稱 每次量 ⽤法 天數
------------------------------------------------------
20230911 Baktar 400mg/Tab (複⽅) 2.00 TIWAC 7

上次出院帶藥 藥品名稱 每次量 ⽤法 天數

------------------------------------------------------------
Sodium chloride 0.9% 500mL/Bot(永豐) 2.00 QD 1
Baktar 400mg/Tab (複⽅) 2.00 TIW 7
NYSTATIN 500,000Unit/Cap 20.00 QDPC 1
Magnesium Oxide 250mg/Tab 0.50 BIDPC 14
Cyproheptadine(液劑)0.4mg/mL 120mL/Bot 2.50 BIDPC 14

無外院⾃備藥

Social and Personal History

抽菸：無
是否暴露於⼆⼿菸環境：否
喝酒：無
嚼檳榔：無
物質濫⽤：無

Allergic History
家屬代述無藥物過敏史

Family History
as pedigree

Review of Systems
General：no unusual weight gain or loss; no fatigue
Skin：no easy bruising or bleeding; no color change; no pruritus; no rashes; no problems
with hair
HEENT：
Head：no trauma
Eyes：no visual changes; no diplopia; no crossed or tendency to cross; no discharge; no
redness; no puffiness; no injuries
Ears：no difficulty with hearing; no earache; no discharge; no ear infections; no ventilation
tubes
Mouth/Throat：no difficulty in swallowing; no sore throat; no hoarseness; no gum bleeding;
no oral thrush; no dental defects
Neck：no asymmetry; no stiffness; no swollen glands; no masses
Breasts：no nipple discharge; no asymmetry; no pain; no lumps
Respiratory：no cough; no sputum; no shortness of breath; no hoarseness; no wheezing; no
snore loudly; no hemoptysis
Cardiovascular：no edema; no cardiac murmur; no cyanosis; no dyspnea on exertion; no
chest pain; no syncope
Gastrointestinal：no vomiting; no diarrhea; no nausea; no blood in stools; no constipation;
no change in appetite; no abdominal pain or discomfort; no jaundice
Genitourinary：no enuresis; no dysuria; no frequency; no polyuria; no pyuria; no hematuria;
no vaginal discharge; no abnormalities of penis or testes
Neuromuscular：no headache; no nervousness; no sleep disturbance; no dizziness; no
convulsion; no ataxia; no muscle or joint pains; no postural deformities
Endocrine：no disturbances of growth; no excessive fluid intake; no polyphagia; no goiter;
no thyroid disease
Hematotologic：no bruise easily; no difficulty stopping bleeds; no lumps under arms, neck;
no fever
rheumatologicskeletal：no pain, stiffness and swollen of joints; no variation in joint pain
during day; no fingers painful/blue in cold; no red eyes; no back pain; no neck pain

Physical Examination
General appearance： Acutely ill;
Consciousness：Well oriented;
body length：99cm (15-50th percentile)
body weight：15.7kg (50th percentile)
Vital signs：
Temperature：36.9℃
Heart rate127/min
Blood pressure：109/76mmHg
Respiratory rate：24/min
Perfusion and oxygenation status： warm, no cyanosis, refilling time < 2 seconds
Integument
Skin：normal skin turgor, no jaundice, no eruptions, no petechiae
Head/Eyes/Ears/Nose/Mouth and Throat：
Head：anterior fontanelle： soft and flat, normal configuration, no scar, no tenderness
Eyes：no exophathalmos, no abnormal discharge
Lids：no ptosis; pink conjunctiva
Sclera：anicteric, no petechiae
Ear drum：bilateral cerumen impaction
Nose：normal configuration, no discharge
Mouth and Throat：
Lips： pink color, no cyanosis, dry lips
Throat： not injected throat, no ulcers
Tongue： no deviation
Neck： supple, no motion limitation, no palpable nodules
Chest：
Inspiration： symmetric, no suprasternal, intercostal or subcostal retraction
Palpation： no tenderness
Auscultation： clear breathing sound
Percussion： resonant and tympanic
Heart
Auscultation： regular heart beats, no murmurs or abnormal heart sounds
Pulses： normal femoral pulses, dorsalis pedis pulses palpable bilaterally
Abdomen：
No scar, normoactive bowel sound, soft, no tenderness, no distension, no palpable mass, no
splenomegaly, no hepatomegaly
Extremities：
no deformity, no fracture, no pitting edema, good perfusion

Laboratory Data
[⾎液]
報告時間 WBC Neu. Lym. Mono. Eos. Baso. MDW MPV
2023-09-24 22：54 8.4 62.4* 26.8* 8.8* 1.3 0.7 19.51 7.5
報告時間 NRBC MCHC MCH MCV PLT RDW Hct Hb
2023-09-24 22：54 - 35.1 29.1 82.9 218 14.4 35.4 12.4
報告時間 RBC
2023-09-24 22：54 4.27
----------------------------------------------------------------------------------
[⾎液⽣化]
報告時間 Glu-AC BUN CRE P Na K ALT AST
2023-09-24 23：29 80 17 0.27 6.0* 139 4.0 11 22
報告時間 脂⾎ 溶⾎
2023-09-24 23：29 0 0
----------------------------------------------------------------------------------
[⾎糖]
報告時間 Glu AC
2023-09-24 23：29 80
----------------------------------------------------------------------------------
[One Touch]
報告時間 Glu-AC
2023-09-24 23：29 80
----------------------------------------------------------------------------------

⽪膚感染評估
病⼈是否為長期臥床或曾居住過長期照護機構：否
機構近兩個⽉是否有其他居住者患過疥瘡：否
病⼈是否有⽪膚疹：否

功能評估
Modified Rankin Scale： 0 No symptoms.

Image Study
無報告

社會⼼理評估
[家庭狀況]
住院期間的主要照顧者：⽗⺟
出院後的主要照顧者：⽗⺟
病⼈重要關係(決策)⼈：稱謂：⺟親，姓名：林倚如，聯絡電話：0989-881-876/0989-
882-057爸
居住狀況：與家⼈同住
家庭經濟狀況：⼩康
有無需要經濟援助：否
有無疑似受虐：否

Diagnosis-Problems
1.Encounter for antineoplastic chemotherapy
2.Acute lymphoblastic leukemia not having achieved remission

Plans
1. Arrange for blincyto target therapy
2. Laboratory evaluation before therapy
3. Monitor side effect of target therapy
4. Keep adequate hydration

營養評估項⽬
⾝⾼： 99cm 體重： 15.7kg
BMI： 16.02 kg/m^2
營養狀態：
正常營養狀態
分數= 0