Name: MR.

KYAWZIN HAN

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Bifth Date: 12105/1983 Age: 36 Y 9 M 9 D Sex: {.tfl (Male)
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Medical Certificate for 101 -20-0003385

Air Travel
-
DR,SURACHAT CHAKRAPEE.SIRISUK OAA')
Physician name Medical License Numoe..
m
at Bangkok Hospital,2 soi Soonvilai 7, New Petchburi Road, Bangkok
MR KYAW zlN HAN
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.El' ort-Prtiunt Date:
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Chief Complaint
Diagnosis (ln case of skin lesion specify the ocation)
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Recommendation N
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i, for air travel f] rit for air travel by air ambulance only -Date N
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,F ,n for air travel by commercial airline with special conditions; a

Escort bry O ooctor C Nrrr" ,..5 ramttytNon-medicat O Non"

Seat type O Stretcher () f irst Class (Flatbed seat) C Business Ctass (Rectining seat) C Regutar seat
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lDR,SURACHAT

I acknowledge all risks during travel by aircraft from physician and voluntary to accept my own risk if I travel against the
medical advices.
SignatUrePatientSignaturePatient,sRelative
[/R. KYAW ZIN HAN

This certification will be valid for 7 days from issued date

Abbreviation: WCHR = Wheelchair Ramp, WCHS = Wheelchair Step, WCHC = Wheelchair for Cabrn

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Medical Certificate Page: [A'1]
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Physician/ Dentist name DR.SIRIMON PIYAVUNNO Medical/ Dental License No. 30211
at Bangkok Hospital, 2 Soi Soonvijai 7, New Petchburi Road, Bangkok
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Visit Date: rclA2l202o o
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Birth Date:12105/1983 Age:36YgM9D Sex: tret (Male)
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t01 -20-0003385
Medical Certificate
Page:lA1l -
Physician/ Dentist name DR,SURACHAT CHAKRAPEE-SIRISUK Medical/ Dentat License No. 9552
at Bangkok Hospital, 2 Soi Soonvijai 7, New Petchburi Road, Bangkok m

I have examined Mr./Mrs./Miss N/R. KYAWZIN HAN (Patient) .

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01 '14098t01CANCEN HN : 01 19040389
EN : O01 191004484 |ANX1220220201211

E.E* BANGKOK z
- "loflnutti{u z nuurvrqet.llfr'prluH nr.irvl1,'r 10310
Soi S'oonvilai Z New petJnaOuri Rd. Bangkok 10310 Thailand
r-9 uosPlrAl Tel, 66-231 0-3000 Fax. 66-231 B-1 546
Contact Center Tel. 1719
www. ba ng kokhos pital. co m

DISCHARGE SUMMARY REPORT

Patient Name : MR. KYAW ZIN HAN

No.
Hospital : 01-19-040389 Age :36Y 9M 10D

Room No. :

Admission Datei Z3l1Zl2O1g Admission Time :09:00

Discharge Date : Discharge Time :

Attending Physician : Sirimon Piyavunno, MD, Hematologist'

Consulting Physician(s) : Surachat Chakrapee-sirisuk, MD, Medical Oncologist.

Allergies
No known allergY
Chief Complaint
Jaundice, cough.
History of Present lllness
He first came to see Hematologist atWattanosoth Hospital, Bangkok Hospital Medical center
on 161712019 due

to splenomegaly, Thrombocytopenia. PET/CT scan on 171712019. Splenectomy was adviced.

lmmunnizations

recommended.

He came on 13l11l2O19.Bnil 2.2, Bili-D 1'0, LDH 254

CT from out side was reviewed.
CT OF THE ABDON/EN, 1 511012019. Comparison : PETCT at WSH, 1710712019.

Spleen : No change in size and appearance of the spleen since the previous study,
measuring about 15.0.18.5 cm in axial dimensions and21.0 cm in vertical span, with clusters
of small nodules with dense rim in lower and central regions. Overall splenic perfusion is less
than that of the liver and the nodules are barely enhanced. The splenic vein is not opacified.
Liver : Presence of a few cysts in segment 2 and 4 with no other maSS.
GB and biliary : No gall stones. No dilatation of intrahepatic ducts or CBD,
Pancreas, adrenal, kidneys, bladder : Normal.
(normal
Gl tract : Displacement of the DJ unction almost to the right border of the spine
position at left of spine) and compression of the proximal part of the stomach. Small bowel
and colon less affected. No bowel obstruction'
Others : No rntraabdominal adenopathy. Minimal free fluid in the pelvic cavity.
Basal chest : No lung nodule or pleural effusion'
probably
Bone : Multiple tiny sclerotic foci in the bones, better outlined on this study but
unchanged. No abnormal bone trabeculation. No fracture or epidural mass'
IMPRESSION :

No change in splenomegaly with multiple nodules with dense rims and

 -l
EN: 001191004484 1ANX222O22O201211 0114098;01CANCEN HN | 0119040389

@ gaNGKOK z tot 4utiaio 7 nuurvr.l:ljrio'lr,rr n:rrvrnr 10310

rJ XOSPITAL 2 Soi Soonvijai 7 New Petchaburi Rd. Bangkok 10310 Thailand
Tel. 66-231 0-3000 Fax. 66-231 B-1 546
Contact Center Tel. '1719
www. bangkokhospital.com

overall poor splenic enhancement. Tissue study.is recommended.

15t11t2019
CXR:PA UPRIGHT
FINDINGS:
No active pulmonary lesion.
No pleural effusion.
Normal heart size and aorta.
The bony thorax is unremarkable.
IMP: Normal chest.
Medical Clearance then Splenectomy on 1Bl1112019.
Patho reported to be AngioSarcoma, High Grade.
He came for follow up on 23i 1212019. Platelets ALP 326 from 265, GGT decreased to '176 from 276, AST 48
from 94, ALT 36 from 79,

Hethe developJaundice, cough in early Fel:2020, Lab in Myanmar on111212020 PT26 (<12), Hb 9.8, Hct
29.8%, Ptt46,000 Biti-T 87.4 (<18.8), ALp 453 (<129), SGPT 120 (<41), SGOT 170(<40),
He came on171212020. Nofever, Drycough, RUQ pain, anorexia.ModeratelyJaunduce, Liver4 FB below RCM,
PET/CT scan reported new developed numerous small non FDG avid bilateral pulmonary metastases.
Diffuse metastases in both lobes of liver.
Widespread bone metastases throughout the whole axial bone, both femora and humeri.
He was admitted for further evaluation and supportive treatment.
Discharge Diagnosis
(1) Principal Diagnosis
AngioSarcoma of spleen post Splenectomy. Hyperprogressive metastases.
Jaundice
(2) Secondary Diagnosis / Co morbidity
Anemia with Thrombocytopenia
Relevant investigation results
ResultRadiology
171212020 Chest PA Result:

COMPARISON: '15i1 112019, FINDINGS:Apparent diffuse coarse trabeculation of the osseous structures;
could be due to hematological disease or marrow disease.Diffuse increased pulmonary marking in both
lungs; still shown.However diffuse fine reticular infiltration in both lungs should be considered.No recent
gross pleural effusion.Normal heart size and airta.

181212020: PET Scan (Result) Result:

History:A case of splenic angiosarcoma undenivent splenectomy in Nov 2019.
EN : O01 191004484 t4NX32202202A1211 01 1 4098i01 CANCEN HN:0119040389

@ BANGKOK z nor4uia6't z nuurrnerioi'ortual -:.r,yn 103 r0

UO UOSPITAL 2 Soi Soonvijai 7 New petchaburi Rd. Bangkok 10310 Thailand
Tel. 66-231 0-3000 Fax. 66-231 B-1 546
Contact Center Tel. 1719
www. bangkokhospital.com

I nd ication : Restag i n g.
Radiopharmaceutical: 1BF-FDG Total activity: 10.3s2 mci
Blood Sugar: 112 mgldl.
Findings of CT Scan :

Contrast enhanced CT scan was perlormed from the skull vertex to both thighs and compared to previous
cr abdomen on 15 oct 20'19 from other hospitar and pET/cr on 1 7 July 201g.
The brain study appears normal. The head and neck structures including thyroid gland are unremarkable.
There is no cervical or supraclavicular adenopathy.
The lung shows interval developed numerous small target-like subsolid nodules scattered in
both lungs
such as a 0.4 cm nodule surrounded with ground-glass at RLL (Se 7; IMA 84). There is no pleural effusion.
No mediastinal or hilar adenopathy is noted. The heart and other mediastinal structures are normal.
The
chest wall and axillae are unremarkable.
Splenectomy has been done. Hepatomegaly with numerous hypoattenuated nodules & masses in both
lobes of liver are developed such as a 6.8 cm mass at segment 3 (Se 4; IMA 116), a 2.6 cm nodule in
segment4 (lN/A 121) and a 1.9 cm nodule in segment 6 (lMA 131). The portal vein is patent. No bite duct
dilatation is seen.
The GB is collapsed. The pancreas, adrenal glands and both kidneys are unremarkable. The pelvic
structures appear normal. The Gl tract is within normal limits. No intraabdominal, paraaortic or pelvic
adenopathy is visualized. Minimal ascites is present.
Diffuse ill-defined lytic lesions throughout the whole skeleton are detected. Focal lytic lesion with minimal
left paravertebralsofttissue at L1 body is observed, about 3 cm in size (lMA 124). No epidural extension is
seen.
Findings of PET Scan :

The attenuation corrected FDG PET is performed from vertex of skull to upper thighs at 60 min after
intravenous injection of the radiotracer.
The follow up study is compared to the previous pET-cr study on llJuly 201g.
ln the brain: The study shows no FDG avid lesion in each cerebral hemisphere.
ln cervicalarea: There is no hypermetabolic activity in nasopharynx, larynx or in oral cavity. No FDG avid
lymph node in cervical or in supraclavicular space is seen.
ln the thorax: New developed multiple small subsolid nodules scattering in both lungs seen in CT scan
show no increased FDG avidity. No hypermetabolic node in mediastinum or hilum is observed.
ln the abdomen: There is newly and irregularly increased FDG uptake in numerous nodules scattering in
both lobes of liver. No hypermetabolic lymph node in retroperitoneal space or in abdomen is detected.
Tracer uptake in pancreas and adrenal gland is unremarkable. No uptake at splenic bed is seen because
of splenectomy.
ln the musculoskeletal system:There is new development of hypermetabolic activity throughout the whole
EN: 00'1191004484 1ANX42202202A1211 0I14O9B;01CANCEN HN;011e04038e

@ saNGKoK z rot quJa{u 7 nuurl,l{?LSpipr1ul nr{rr1,,r 10310

r-il
uosPlTAL 2 Soi Soonvijai 7 New Petchaburi Rd, Bangkok 10310 Thaitand
Tel. 66-231 0-3000 Fax, 66-231 B-1 546
Contact Center Tel, 1719
www. bangkokhospital.com

skeleton.
PET/CT IMPRESSION:
ComparedtothepreviousPET-CTstudyon JulylT,20.lg,therearenewdevelopednumeroussmall non
FDG avid bilateral pulmonary metastases.
Diffuse metastases in both lobes of liver.
Widespread bone metastases throughout the whole axial bone, both femora and humeri.
Complete Blood Count
22 Feb 2020 05:53
Hemoglobin (Hb) 8.4 g/dL (13-18)
Corrected WBC 7.49 *'10^3/mm3 (4-10)
Total WBC 13.26.10^3/mm3 (4-10)
Platelet Count 34 10^3/mm3 (150-450)
Red Blood Cell 3.48 .'10^6/mm3 (4.5-5.9)
Hematocrit (Hct) 26.8 % (40-54)
MCV 77 .1 fL (80-100)
MCH 24.1 pg (26-34)
N/CHC 31.2gtdL (31-37)
% Neutroph n 73.1 % (46.5-75)
Neutrophils 9693 /mm3 (2000-7500)
% Lymphocyle 17.7 % (12-44)
Lymphocytes 2347 /mm3 (1500-4000)
% Monocyte 8.1 % (0-11.2)
Monocytes 1074 lmm3 (200-1000)
% Eosinophil 0.6 % (0-9.5)
Eosinophils 80 /mm3 (40-700)
% Basophil 0.5 % (0-2.5)
Basophils 66 /mm3 (0-200)
NRBC 77 l100wbc
RDW 25.8 % (e-15)
MPV 7.3 fL (6-12)
Platelet Count by Manaul Slide Review 3
Platelet Comment Decrease
RBC Morphology Abnormal RBC morphology seen see comment below
Giant Platelet Seen
Hypochromia 1

Microcytosis 1

Polychromasia 1
EN: 001191004484 1ANX5220220201211 0.114098;01CANCEN HN:0119040389

fq FANgKqf 2 {oe4uJa,{'r 7 ouurylr?il$fr'Frluru nq+vrvr rosio

L, HOSPITAL 2 soi soonvijai 7 New petchaburi Rd. Banskok 10310 Thairand
Tel. 66-231 0-3000 Fax. 66-231 B-1 546
Contact Center Tel. 1719
www. ba n gkokhospital.com

Ovalocytosis Few
Target Cell 1

Schistocyte Few
LD H(Lactate Dehydrogenase)
17 Feb 2020 11'.30
LDH(Lactate Dehydrogenase) 946 U/L (125-220)
Hemoglobin Typing
17 Fel:2020 11'.30
MCV 76.4 fL (80-100)
MCr,23.7 pg (26-34)
Hb typing A2A, Not rule out Alpha Thalassemia: Plese confirm Alpha Thalassemia by PCR method.
CF test Positive.
Hb 42 1.9 % (0-3.5)
Hb A 98.1 %
Leukodepleted Single Donor Platelet-Closed System (SDPCL) 1 Unit
22 Feb 2020 08:45
Blood Group BP
Sodium
17 Fet> 2020 11'.30
Sodium '135 mmol/L (136-145)
Coagulation Profile
17 Feb 202011'.30
.17.1
Prothrombin Time (PT) Secs. (10.5-13.4)
tNR 1.52
APTT 31.3 Secs. (22.5-31.6)
Thrombin Time (TT) 19 Secs. (15-22)
Coag comment Repeated result
Specimen type 3.2
Mean of Reference Range 26.96 Secs.
Creatinine (plus eGFR)
17 Feb 2020 11'.30
Creatinine 0.71 mg/dl (.73-1.18)
eGFR for Thai 136.22 ml/min/1 .73 m2
eGFR (African-American) 139.89 ml/min/1 .73 m2
eGFR (Non African-American) 120.7 mlimin/1 .73 m2
eGFR Comment Calculated by CKD - EPI formula according to National kidney foundation
recommendation. This equation should only be used for patients'18 and older.
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EN : O01 1 91 004484 14NX6224220241211 01 '14098;0'l CANCEN HN : 01'1S040389

BANGKOK 2 'x0uFtufllsL 7 nuuLflt:Linn LilN n?{"ry,{ 10310

HOSPITAT 2 Soi Soonvijai Z New Petcnabur Rd.-Bangt<on',0:f O Thailand
Tel. 66-231 0-3000 Fax. 66-23.1 B-1 546
Contact Center Tel. '1719
www. bangkokhospital.com

Direct Coombs TesI-DAT-CENTBLOOD

17 Feb 2020 11'.30
Direct Coombs Test Positlve 3+
Blood Urea Nitrogen
17 Feb 2020 11'.30
Blood Urea NitrogenT.T mg/dl (8.9-20.6)
Glucose (Fasting)
17 Feb 2020 11:30
Glucose (Fasting) 97 mg/dL (70-99)
Total lron Binding Capacity
17 Feb 2020 11'.30
TIBC 380 ug/dL (250-450)
UIBC 306 ug/dL (69-240)
Serum lron 74 ug/dL (65-175)
Potassium
17 Feb 2020 11'.30
Potassium 3.63 mmol/L (3.5-5.1)
ANA Profile
17 Feb 2020 13'.47
Reference Range (Normal range : less than 1:80)
Anti-dsDNA Result Negative
Anti-n RNP Negative
Method lndirect lmmunofluorescence and Enzyme- linked lmmunosorbent assay
Anti-ds DNA <10 lU/mL
Anti smith Ratio 0.07
Anti nRNP Ratio 0.1
Reference range (Negative < 100 lU/mL)
Specimen Serum
Reference Range (Negative : Ratio < '1)

Reference Range (Negative : Ratio < 1)

Reference Range; (Normal range : less than 1:80)

ANA(ANF,FANA) NEGATIVE
Cytoplasmic staining N EGATIVE
Anti Smith Negative
ANA Pattern *Anti-nuclear pattern
ANA Pattern *Cytoplasm pattern
ANA Pattern *Auto-antibodies
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EN : O01 191004484 l'4NX72202202A121 1 01'14098;0'lCANCEN HN : 01'19040389

BANGKOK 2 .I 0t FluErGlt 7 nuuLl,!,rr!5

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?.t,}ll,,J' 03 1 0
HOSPITAL 2 Soi Soonvijai 7 New Petchaburi Rd. Bangkok 10310 Thailand
Tel. 66-2310-3000 Fax. 66-231 8-1 546
Contact Center Tel. '1719
www. bangkokhospital.com

Complete Blood Count

17 Feb 2020 11'.30
Hemoglobin (Hb) 8.9 g/dl (13-18)
Corrected WBC 6.27 *10^3imm3 (4-10)
Total WBC 7.96.10^3imm3 (4-10)
Platelet Count 40 10^3/mm3 (150-450)
Red Blood Cell 3.74 *10^6/mm3 (4.5-5.9)
Hematocrit (Hct) 28.5 % (40-54)
MCV 76.4 fL (80-100)
lvlcH 23.7 pg (26-34)
MCHC 31 s/dl (31-37)
o/" (46.5-75)
% Neutrophil 63.2
Schistocyte Few
Neutrophils 5031 /mm3 (2000-7500)
% Lymphocyle 27 .B o/" (12-44)
Lymphocytes 2213 /mm3 (1500-4000)
% Monocyte 7.4 % (0-11.2)
Monocytes 589 /mm3 (200-1000)
%Eosinophil 1%(0-9.5)
Eosinophils B0 /mm3 (40-700)
% Basophil 0.6 % (0-2 5)
Basophils 48 /mm3 (0-200)
NRBC 27 l100wbc
RDW 26.4 % (e-15)
MPV 8.4 fL (6-12)
Platelet Count by Manaul Slide Review 3
Platelet Comment Decrease
RBC Morphology Abnormal RBC morphology seen see comment below
Hypochromia 1

Microcytosis'1
Polychromasia 1

Ovalocytosis Few
Target Cell '1

Liver function test (TP,Bili,OT,PT,AIk,Chol,GGT)

17 Feb 2020 11:30
Bilirubin (Total) 14.9 mg/dL (.3'1.2)
Bilirubin (Direct) 10.6 mg/dL (0-.5)
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EN : O01 191004484 t4NX8220220201211 01 14098:0lCANCEN HN:0'119040389

@ saNGKoK z rol4utiaA'l z nuurtraljd'or1uil r?.lLylr 10310

!.,
HOSPITAL 2 Soi Soonvilai 7 New petchaburi Rd. Bangkok.l0310 Thailand
Tel. 66-231 0-3000 Fax. 66-231 B-.1 546
Contact Center Tel. 1719
www. ba ngkokhosprtal.com

ALP 401 U/L (40_150)

GGT 142UtL(12_64)
ALT (SGPT) 12s UtL (0_55)
AST (SGOT) 1e5 U/L (5_34)
Totat Protein 6.02 g/dL (6.a-8.3)
Albumin 3.02 g/dL (3.S-5.2)
Globulin 3.05 g/dL (2.1-3.7)
tuG Ratio 0.99 (1-2)
Cholesterot 148 mg/dL <200
Alpha Fetoprotein (AFP) (BGH)
20 Feb 202017:35
AFP 1.55 ng/ml (0-7)
AFP (Alpha Fetoprotein) 1.32 nglml (.89_8.78)
LDPRC 1 Unit
22 Feb 2020 08:45
Blood Group BP
Antibody Screening Negative for antibody screening
Albumin
20 Feb 2020 17:35
Albumin Z.B gtdL (3.S-5.2)
Bilirubin (Total,Direct)
20 Feb 2020 17'.35
Bilirubin (Totat) t4.Z mgtdL (.3-j.Z)
Bilirubin (Direct) 10.2 mg/dL (0-.S)
Specimen Comment: lcterus 1+
Prothrombin Time
20 Feb 202017:35
Prothrombin Time (pT) 2.1.5 Secs. (10.5_13.4)
tNR 1.96
Specimen type 3.2
Glucose (Random)
20 Feb 2020 17:35
Glucose (Random) 141 mgldL
Pending results
Liquid Biopsy Guardant 360.
Hospital Course , Medication(s) and Treatment
lnfectious doctor ruleout infectious cause.
tr/i/ nn 1 nn 4 o^,, E /4.
EN : O01 1 91 004484 14NX922A2202A1211 01 1 4098;01 CANCEN HN : 01 19040389

ffi 3g1r1GKOK 2 %orquda,i.'r nu

E HOSPITAL 2 soi Soonvijai z New petchaburi Rd. Banskok 1o3io rhaitand
Tel. 66-231 0-3000 Fax. 66-231 B-1 546
Contact Center Tel, 1219

.ough r.. rrr r* ca

The patient and father were informed of status of the disease.
Currently available Chemotherapy or targeted therapy cannot be given due to the abnormal
level of liver
fu nction.

Next Generation gene sequencing from prior tissue or new biopy tissue was discussed.
Liquid Biopsy from blood sample (with faster result and less risky compare to new biopsy) was finally
done.
Blood transfusion as LDPRC, SDP were given to the patient to keep level of Hemoglobin >B gm/dl and platelet
count > 20,000 mm3 ( or > 60,000/mm3 during air-traveling )
Patient was discharged.
Waiting for Liquid Biopsy result.
Treatment Plan
Supportive care
Discharge lnstructions / Recommendations
At his home town, He need to be taken care by Gl doctor, oncologist.
Follow - up Arrangements
With SURACHAT CHAKRAPEE-SIRISUK,M D.
Discharge Medication
See Home Medication Sheet
Patient's condition upon discharge
lmproved
Type of Discharge
With Approval

Sincerely yW, ':ii.ii

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Medical License No.9552 .

Dale:22t0212020 Time : t3:47 hr.

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