Case presentation-Chronic Myeloid Leukemia
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This document summarizes a medical case presentation involving a 25-year-old male patient who presented with dizziness, fatigue, and abdominal swelling. On examination, the patient was pale and wasted with massive splenomegaly. Laboratory tests found normocytic anemia and leukocytosis. A peripheral blood smear showed dysplastic granulocytes suggestive of chronic myeloid leukemia (CML). The patient was referred to the oncology unit for further treatment of CML.
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Case presentation-Chronic Myeloid Leukemia
- 1. Medicine case Presentation Consultants: Professor Sir Isi Kevau Dr Amana, Dr Maino Registrars: Dr Ken and Dr Baiwan Dr Ona and Dr Ben RMO: Dr Moide Medical Students: Osito Hagayo, Elmaritta Kemba, Anderson Perea.
- 2. Patient identification Data ▪ Patient initial: KS ▪ Sex/age: Male/25 ▪ Origin: Pogera,Liagam District, Enga Province ▪ Place of Residence: Morata ▪ Admission Detail: Patient was admitted on the 17th April via Emergency Department at around 7pm. ▪ Source of History: Patient ▪ Religion: Apostolic ▪ Next of Kin: Brother
- 3. Presenting symptoms ▪ Dizziness and fatigue 3/12
- 4. Background history ▪ Two years ago the patient developed the abdominal swelling from the left upper quadrant and has progressively increase in size till present. The swelling has caused abdominal discomfort (early satiety, abdominal fullness) ▪ He has been visiting different hospitals (Wabag General Hospital and Kudzip Hospital) with the above complain but no help was given. ▪ Early this year he traveled to Port Moresby and due to worsening symptoms he presented to ED PMGH.
- 5. History of presenting illness ▪ The patient has become progressively weak over the past 3/12s, and he tires easily walking short distances and was unable to do his normal activities. ▪ He experienced episodes of dizziness and almost fainted on prolonged standing. This prompted relatives to bring him to the Port Moresby General hospital.
- 6. Specific interrogation ▪ He denies: ▪ Pruritus ▪ Bruises ▪ Bleeding from gums ▪ Joint pain ▪ He admits: ▪ Dyspnea on exertion ▪ Night sweats. ▪ He has lost his appetite ▪ Lost a significant amount of weight.
- 7. System Review ▪ Respiratory system: ▪ No cough ▪ No haemoptysis ▪ GIT: ▪ No rectal bleeding or melena ▪ No change in bowel habit ▪ No vomiting ▪ No abdominal pain ▪ No jaundice ▪ Cardiovascular system: ▪ No chest pain on exertion ▪ No palpitation ▪ No paroxysmal Nocturnal Dyspnea ▪ No orthopnea ▪ Central Nervous System: ▪ No head ache ▪ No photophobia/visual disturbances ▪ No confusion ▪ Genitourinary system ▪ No hematuria
- 8. Past Medical history ▪ First admission ▪ No personal History of Tuberculosis, diabetes, Hypertension, Malaria ▪ Unaware of any drug allergy
- 9. Family history ▪ 1st born in a family of eight (8) ▪ All siblings alive and well ▪ No family history of Leukemia or other bleeding disorder, TB, Diabetes, Hypertension or other malignancy.
- 10. Social History ▪ Not married ▪ He did not attend school ▪ Subsistence farmer ▪ Currently living at Morata Settlement ▪ Habits ▪ Chew betelnut and drink beer occasionally ▪ Does not smoke
- 11. Examination General Observation ▪ Melanesian male sitting up in bed, not in any respiratory distress ▪ Pale ▪ Wasted ▪ Distended abdomen Vitals ▪ BP:100/60 mmHg ▪ PR: 110 beats/minute RTA bounding in nature ▪ RR: 24 breaths/minute ▪ Temperature: 37.5 ▪ Weight: 40Kg ▪ Height:150cm ▪ BMI: 16kg/m2
- 12. Hematopoietic system examination ▪ Inspection: ▪ Hands ▪ Palmar Pallor ▪ No koilonychia ▪ Face ▪ Conjunctival pallor ▪ Soft palate pallor ▪ No gum hypertrophy/haemorrhage ▪ No angular stomatitis ▪ Skin ▪ No petechiae or ecchymosis, ▪ No scratch mark. ▪ No joint swelling ▪ Palpation: ▪ No palpable lymph nodes (epitrochlear, cervical, supraclavicular, axillary and inguinal) ▪ No bone tenderness ▪ Massive splenomegaly 30 cm from the left coastal margin to right groin and inguinal area. ▪ No hepatomegaly
- 13. Gastrointestinal examination Inspection: ▪ Hands ▪ No peripheral stigmata of chronic liver disease ▪ Face ▪ No scleral icterus ▪ Chest ▪ No gynecomastia ▪ No scanty hair in axillar ▪ Abdomen ▪ Asymmetrical distended abdomen Palpation: ▪ Splenomegaly 30 cm from sub coastal margin to right groin and inguinal area and extending to left flank ▪ No hepatomegaly ▪ No signs of ascites (no shifting dullness or fluid thrill)
- 14. Respiratory system examination ▪ Inspection ▪ Hands: ▪ No Hypertrophy pulmonary osteoarthropathy ▪ No peripheral cyanosis ▪ Face/neck: ▪ No tracheal tug ▪ Chest ▪ No use accessory breathing muscle ▪ Chest symmetrical, no deformity ▪ Palpation: ▪ Trachea midline ▪ Chest expansion equal on both side ▪ Percussion ▪ No dullness or hyper resonance to percussion bilaterally ▪ Auscultation ▪ Air entry equal ▪ Vesicular breath sound ▪ No added sound
- 15. Cardiovascular system Examination Inspection ▪ Hands ▪ No peripheral stigmata of infective endocarditis ▪ Face/neck ▪ JVP not raised ▪ Chest ▪ No visible pulsation Palpation ▪ Apex beat 5th LICS MCL ▪ No heaves or thrill Auscultation Hyperdynamic two heart sound No murmur
- 16. Central Nervous System examination ▪ Higher function: ▪ Conscious ▪ OTPP ▪ Right handed ▪ Cranial nerves intact ▪ No signs of meningeal irritation ▪ Motor examination: ▪ Tone is normal ▪ Power is 5/5 Reflex Right Left Finger ++ ++ Supinator ++ ++ Biceps ++ ++ Triceps ++ ++ Knee jerk ++ ++ Ankle jerk ++ ++ Plantar Normal Normal
- 17. Problem list Subjective ▪ Tiredness and lethargy ▪ Dizziness and fatigue ▪ Dyspnea on exertion ▪ Abdominal swelling and discomfort ▪ Weight loss ▪ Night sweats ▪ Early satiety Objective ▪ Pallor ▪ Wide pulse pressure ▪ Tachycardic ▪ Wasted ▪ Asymmetrical distended abdomen ▪ Massive splenomegaly
- 18. Case summary ▪ KS M/28 presents with clinical findings of myeloproliferative disorder with associated anemia and a hyperdynamic circulation state.
- 19. Provisional Diagnosis ▪ Chronic Myeloid leukemia Differential diagnosis: ▪ Hyperreactive malarial splenomegaly. ▪ Lymphoma ▪ Myelofibrosis
- 20. Management ▪ Admit to ward for further investigation and management ▪ Symptomatic treatment ▪ Blood transfusion ▪ 23rd , 24th and 27th -1 unit whole blood ▪ Fefol 2 tablet ‘O’ BD ▪ Obtain medical oncologist opinion
- 21. Investigation ▪ Full Blood Examination ▪ Blood film ▪ Bone marrow biopsy ▪ Philadelphia chromosome (BCR/ABL)
- 22. Full Blood Examination 17/4/17 20/4/17 25/4/17 27/4/17 Comment RBC 1.59 𝐱 𝟏𝟎 𝟔 /uL 1.72 𝐱 𝟏𝟎 𝟔 /uL 1.93 𝐱 𝟏𝟎 𝟔 /uL 2.23 𝐱 𝟏𝟎 𝟔 /uL HCT 14.8% 18.1 % 17.9 % 19.6 % Hb: 5 g/dL 5.1 g/dL 5.7 g/dL 6.4 g/dL Normochromic normocytic anemia MCV 93.1 fL 107 fL 92.2 fL 87 fL MCH 31.4 pg 29.7 pg 29.5 pg 28 pg MCHC 33.8 g/dL 27.7 g/dL 32 g/dL 32 g/dL WCC 432.18 𝐱 𝟏𝟎 𝟑 /uL 398.98 𝐱 𝟏𝟎 𝟑 /uL 367.09 𝐱 𝟏𝟎 𝟑 /uL 361.26 𝐱 𝟏𝟎 𝟑 /uL Leukocytosis Neutrophil 348.1 𝐱 𝟏𝟎 𝟑 /uL 316.4 𝐱 𝟏𝟎 𝟑 /uL 290 𝐱 𝟏𝟎 𝟑 /uL 283 𝐱 𝟏𝟎 𝟑 /uL Neutrophilia Lymphocyte 23.4 x 103 /uL 42.7 x 103 /uL 32 x 103 /uL 30.2 Monocyte 37.4 x 103 /uL 19.8 x 103 /uL 25 x 103 /uL 21 x 103 /uL Eosinophil 13.9 x 103 /uL 13.1 x 103 /uL 3 x 103 /uL 5 x 103 /uL Basophil 2.2 x 103 /uL 7.1 x 103 /uL 14 x 103 /uL 20 x 103 /uL Platelet 80 𝐱 𝟏𝟎 𝟑 /uL 94 𝐱 𝟏𝟎 𝟑 /uL 138 𝐱 𝟏𝟎 𝟑 /uL 144 𝐱 𝟏𝟎 𝟑 /uL Thrombocytopenia
- 23. Biochemistry Test Result Liver Function Test • Total protein • Albumin • AST • ALT • ALKP • GGT • Total Bilirubin • 65 • 32 • 6 • 6 • 92 • 33 BUN 3.5 Serum electrolytes • Potassium • Sodium 4.9 138 Creatinine 102 Chloride 102
- 24. Peripheral blood film result -25/4/2017 ▪ Markedly elevated dysplastic granulocytes with prominent eosinophilia. Features are suggestive of CML in chronic phase. ▪ For Bone marrow Biopsy and Philadelphia study.
- 25. Progress note ▪ Patient was transferred to oncology unit as a case of CML for further treatment.
- 26. ▪ Thankyou