clinical meeting

1. Dr. KANTA HALDER
Resident (MD;Phase A)
BICH

2. Particulars of the patient
 Name: Rim
 Age: 2years 1month
 Sex: Female
 Informant: Mother
 Address: Faridpur
 Date of Admission: 23.11.2014
 Date of Examination: 15.03.2015

3. Chief Complaints
 Fever for 1 month
 Progressive pallor for 15 days
 Multiple blackish spot on back and
chest for same duration

4. History of present illness:
According to the statement of mother Rim was
resonably well 1 month back. Then she developed
fever which was low grade , intermittent in nature,
not associated with chills and rigor and subsided
by taking antipyratics. She also developed
progreesive pallor for 15 days. Mother also
noticed multiple blackish spot on the back and
chest of her child for same duration.
She had no history of radiation or chemical
exposure, gum hypertrophy, proptosis, headache,
convulsion or travelling to any endemic zone.

5. Cont..
With these complaints, she was treated by a
local doctor who referred her to Dhaka Shishu
Hospital for further evaluation and better
management.

6. History of Past illness:
She had no significant past illness
Birth History :
She was delivered by LUCS at term at home
without any perinatal complication.

7. Feeding History:
She was on exclusive breast feeding upto first
6 months, then proper complementary
feeding was started. Now she is on family diet.
Immunization History:
She is immunized as per EPI schedule

8. Familly History :
There is no history of such type of illness in her
familly
Socio-economic History :
She came from a middle class familly.She is
living in a tin-shed house,drinks boil water and
uses sanitary latrine

9. Treatment History
She received blood and blood product transfusion
for several times and oral and injectable
medications after admission.
Developmental History
She is developmentaly age appropriate.

10. General Examination :
 Appearance: ill-looking
Anaemia: Mild
Jaundice:
Cyanosis:
Clubbing:
Koilonychia: Absent
Oedema:
Dehydration:

11. Cont..
Skin: BCG mark present.There is a procedure
mark present over right leg.
Bony tenderness: Absent
Lymphnode: Not palpable
Signs of meningeal irritation: Absent
Neck Vein: Not engorged
Ear:
Nose: Normal
Throat:

12. Cont..
Vital Signs:
Heart Rate: 90 beat/min
Respiratory Rate: 22 breath /min
Temperature: 99°F
Blood Pressure: 80/50 mmHg

13. Anthropometry:
Cont..
Weight: 9.5 kg
Height: 77cm
WAZ: -2.7 SD (Moderate underweight)
HAZ: -0.8 SD (Mildly stunted)
WHZ: -3 SD (Moderately wasted)

14. Systemic Examination
Hemopoietic System:
 Mouth and Oral Cavity: Normal
 Anaemia: Mild
 Jaundice: Absent
 No lymphadenopathy
 No bony Tenderness

15.  Inspection: Abdomen is not distended ,
scaphoid shape,umbillicus is centraly
placed
 Palpation:
Abdomen is non-tender
No Organomegaly
Abdomen:
Percussion:No Ascitis
Auscultation: Bowel sound present
Other Systemic examination: No abnormality

16. Salient feature
Rim ,2 years old girl,3rd issue of non-
consanguinous parents,fully immunized was
admitted in this hospital with the complaints of
fever for 1 month which was low grade ,
intermittent in nature ,not associated with chills
and rigor and relieved by taking antipyratics.she
also developed progressive pallor and multiple
blackish spot on back and chest for 15 days.She
had no h/o radiation and chemical exposure ,no
gum hypertrophy,no proptosis, headache or
convulsion and no h/o visiting to any endemic
zone.

17. Cont..
Rim is afebrile, mildly anaemic,having a
procedure mark on her right leg.There is no
lymphadenopathy or bony tenderness, no
organomegaly.Other systemic examination
reveals normal findings.

18. Provisional Diagnosis:
Acute Leukemia ;most probably Acute
Lymphoblastic Leukemia(on remission).
Differential Diagnosis:
 Acute Myeloblastic Leukemia
 Kala-azar

19. Investigations:
Complete Blood Count :
• Hb: 5gm/dl
• WBC: Total count: 21,000/cumm
Differential count:
o Neutrophil: 02%
o Lymphocyte: 10%
o Monocyte: 01%
o Eosinophil: 01%
o Blast cells : 86%

20. Cont..
• Platelet : 66,000/cumm
PBF: RBC shows anisochromia with
anisocytosis, many blast cells, platelets
are reduced.
Comment: Suggestive of ALL.
Blood grouping & Rh typing: B positive.

21. Cont..
Bone Marrow Study:
• Hypercellular marrow
• M/E ratio raised
• Erythropoiesis grossly depressed but
normoblastic
• Myelopoiesis – hyperactive with left shift ,
• Megakaryocytes scanty
• Marrow is infiltrated by >90% blast cells which
are morphologically resembling lymphoblast.
Comments: Acute Lymphoblastic Leukemia (FAB)
L1

22. Cont..
SGPT: 36 U/L
S. Uric Acid: 176 µmol/L
S. Creatinine: 32 µmol/L
S. Electrolyte: Na⁺-137 mmol/L
K⁺-4.2 mmol/L
Cl⁻-101.2 mmol/L
 ICT for Kala-azar: Negative

23. FINAL DIAGNOSIS
Acute Lymphoblastic Leukemia
FAB- L1 (on remission)

24. Management :
A.Councelling: About disease
B.Supportive:
 Isolation of the patient
 Neutropenic diet
 Hydration(3L/24hr)
 Alkalization of urine
 Antibiotic
 Tab.Allopurinol
 Blood Product transfusion

25. Cont..
C.Specific treatement:
Protocol based Multistage Polyagent
Chemotherapy
D.Bone Marrow Transplantation.

26. Thank You