Mrs. Susan Derrick is a 77-year-old female who comes to the office with complaints of increasing symptoms of lethargy; fever, night sweats, a 15 lb. weight loss over 6 months; bleeding gums when she brushes her teeth; purplish patches in the skin; and shortness of breath. She also reports a feeling of deep pain in her bones and joints, worse than her usual arthritis pain. She notes that her employment history includes working at a dry-cleaning shop for 15 years, with an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias). She currently lives with her son and daughter-in-law and their teenage son in a single family home. She has Medicare, a Medicare supplement plan and has a modest social security payment each month. She is financially comfortable living with her family. Generally she has been in good health, only treated for hypertension, occasional gastric reflux and osteoarthritis – worse in left hip.HPI: As stated in case above.
Allergies: NKDA
Medications:
• Omeperzol 20mg po daily
• HCTZ 25mg po daily
• Acetaminophen 325mg 2 po every 6 hours PRN hip pain
PE: Enlarged lymph nodes and swelling or discomfort in the abdomen.
You diagnose this patient with acute lymphoblastic leukemia (ALL).
ANSWER THE FOLLOWING QUESTIONS:
- What additional history about her past work environment would you explore?
- What additional objective data will you be assessing for?
- What tests will you order? Describe at least four lab tests.
- What are the differential diagnoses that you are considering? Describe two.
- List at least two diagnostic tests you will order to confirm the diagnosis of ALL.
- Will you be looking for a consultation? Please explain.
- As the primary care provider for this patient with ALL:
• Describe the education and follow-up you will provide to this patient during and after treatment by the hematologist-oncologist.
• Describe at least three (3) roles as the PCP for the ongoing care of the ALL patient.
Full Answer Section
Objective Data:
- Vital signs: Measure temperature, pulse, respiration, and blood pressure.
- Physical examination: Look for pallor, petechiae, purpura, lymphadenopathy, organomegaly, skin lesions, and joint tenderness.
- Neurological examination: Assess for mental status, reflexes, and any signs of central nervous system involvement.
3. Laboratory Tests:
- Complete blood count (CBC): This checks for anemia, low white blood cell (WBC) count, and abnormal cell types.
- Blood smear: This provides a visual analysis of blood cells for morphological abnormalities.
- Bone marrow aspiration and biopsy: This definitive test diagnoses ALL by examining bone marrow cells under a microscope.
- Serum biochemical panel: This evaluates liver and kidney function and checks for electrolyte imbalances.
- Cytogenetic analysis: This analyzes chromosomal abnormalities associated with ALL.
- Flow cytometry: This identifies surface markers on leukemia cells to determine the specific type of ALL.
4. Differential Diagnoses:
- Aplastic anemia: This condition also presents with low blood cell counts but has different causes and bone marrow findings.
- Disseminated intravascular coagulation (DIC): This can cause bleeding and skin lesions but has different laboratory abnormalities.
5. Diagnostic Tests for ALL Confirmation:
- Bone marrow aspiration and biopsy: This remains the gold standard for diagnosing ALL.
- Flow cytometry: This further classifies the type of ALL based on cell surface markers.
- Cytogenetic analysis: This helps identify specific genetic abnormalities that inform prognosis and treatment options.
6. Consultation:
- Yes, a consultation with a hematologist-oncologist is crucial for definitive diagnosis, treatment planning, and ongoing management of ALL.
7. PCP Role in ALL Care:
- **Education and **
- Educate the patient and family about ALL, treatment options, side effects, and supportive care.
- Monitor for treatment complications and manage symptoms like pain, nausea, and infections.
- Coordinate care with the hematologist-oncologist and other specialists.
- Provide emotional support and connect the patient with resources like support groups.
- Ongoing care roles:
- Monitor for relapse and disease progression through regular blood tests and imaging.
- Manage long-term effects of treatment, including potential secondary cancers and chronic health conditions.
- Advocate for the patient's needs and liaise with insurance companies.
- Provide preventive care and address other health concerns alongside ALL management.
By diligently gathering additional information, ordering appropriate tests, and collaborating with specialists, the primary care physician can play a crucial role in supporting and guiding Mrs. Derrick through her ALL diagnosis and treatment journey.