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Exhibits

Nurses' Notes

Day 4, 0905:

Child is resting comfortably in bed. Alert and oriented to time, place, and person. Caregivers report child has been interactive and showing increased interest in eating. Child engages with staff and caregivers appropriately for age. No headache and no pain reported during neck flexion. Brudzinski and Kernig signs are negative. Mucous membranes are moist. Skin is warm, without cyanosis and capillary refill is less than 2 seconds. Pupils are equal round and reactive to light accommodation, with no squint observed in room lighting Lungs clear to auscultation. S, and S2 heard without murmurs. Abdomen is soft and nontender, with hypoactive bowel sounds in all quadrants.

Vital Signs

Day 4, 0905:

Temperature 37° C (98.6° F)

Heart rate 90/min Respiratory rate 22/min

Blood pressure 105/68 mm Hg

Oxygen saturation 98% on room air

Weight 20 kg (44 lb)

A. Mucosal ulceration: This is an acute side effect of radiation therapy that typically occurs during or shortly after treatment, not a late effect. It results from damage to rapidly dividing mucosal cells and usually resolves after therapy ends.

B. Desquamation: Skin peeling or desquamation is an acute reaction occurring within days to weeks after radiation exposure and is not a late adverse effect. It happens due to the breakdown of epidermal cells but heals once the radiation stops.

C. Nausea: Nausea is commonly an immediate or early side effect related to radiation therapy, especially when the brain or gastrointestinal tract is involved. It is often managed symptomatically and usually resolves after completion of therapy.

D. Short stature: Growth retardation or short stature is a recognized late adverse effect of radiation therapy in children, especially when the brain or growth centers are irradiated. Radiation can impair pituitary hormone production or directly affect bone growth plates, leading to permanent growth deficits that manifest months to years after treatment.

• Neurologic: Neurologic symptoms such as lethargy, nuchal rigidity, and headache strongly indicate bacterial meningitis due to infection of the CNS. ALL can also cause neurologic signs through leukemic infiltration of the CNS. These symptoms are not typical in Hodgkin lymphoma.
• Skin: Petechiae commonly occur in ALL because of thrombocytopenia from bone marrow involvement, and they can appear in bacterial meningitis due to septicemia. Hodgkin lymphoma rarely causes petechiae without marrow involvement.
• Pain: Headache and nausea are classic for meningitis due to meningeal inflammation. Pain would only occur in ALL if there is CNS involvement. Hodgkin lymphoma usually does not cause acute pain or meningeal symptoms.
• Lymph nodes: Cervical lymphadenopathy is a defining feature of Hodgkin lymphoma. It also occurs in ALL due to leukemic infiltration, but it is not typical or prominent in bacterial meningitis.