Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in a clinic at a haematology department. Your next patient is called Boba Tee – a 68-year-old lady who has been referred by General Practice querying Leukaemia for fever and unexplained bruising. Please take a history and perform an appropriate examination.
Patient History:
Over the past few months, you have been feeling unwell. You do have an occasional low-grade fever, which is unexplained.
After finding out you have unexplained bruising around your lower limbs, you started to become worried, so you went to see your GP, which sent you to be seen by haematology. You have lost over 10 kg over the last month unexplained. Everything seems to be very odd!
You do often get night sweats. You feel tired and always stay in bed. You sometimes feel dizzy and short of breath when you exert yourself. You feel your face has gone whiter than usual. Everything doesn't seem quite right, and it is only getting worse.
No recent trauma or injury. Waterwork and Bowel normal. You are not aware if you are bleeding anywhere.
Ideas, Concerns, Expectations:
You have no idea what is happening, but you have a condition called polycythaemia vera, which you think might be related. You are concerned as your health is deteriorating. You would like to seek any treatment and find out what is going on!
Past Medical History:
Polycythaemia Vera.
Drug History:
Aspirin 75mg OD, regular venesections, NKDA.
Family History:
Nil.
Social History:
Ex-smoker – used to smoke 20 cigarettes/day for 40+ years. Used to work in a rubber and shoe manufacturing company. Lives in sheltered accommodation. Mostly independent.
Examination Findings:
Pallor. Mucosal bleeding.
Hepatosplenomegaly.
Petechiae and abnormal bruising can be seen at various sites around the lower limbs.
Differentials:
To rule out Leukaemia
Vasculitis
HSP
ITP
Investigations:
Bloods:
FBC (pancytopenia i.e. anaemia/leukopenia/ thrombocytopenia)
Blood film – blast cells in ALL/AML/ CML, smear/smudge cells in CLL, Auer rods in AML
Lactate dehydrogenase (LDH) - often raised in leukaemia
U&Es / LFT – before initiating chemotherapy
Coagulation Screen
U&Es / Bone profile / Uric acid – baseline before chemotherapy
Imaging:
CXR (infection /signs of heart disease mediastinal lymphadenopathy)
CT/ MRI / PET for staging and assessing for lymphoma/ other tumours.
Special Tests:
Bone marrow biopsy - aspiration/ trephine – definitive diagnosis of leukaemia
Lymph node biopsy (assess lymph node involvement) if appropriate
Lumbar puncture (if CNS is involved – may find malignant cells)
Genetic testing Consider : CML + ALL associated with Philadelphia chromosome (t(g:22) translocation)
HLA antigen typing to match suitable donors for stem cell transplant, cytogenic investigations, flow cytometry (myeloid antigens on blast), fluorescence in situ hybridisation (FISH)
Multiple-gated acquisition (MUGA)/ ECG / Echo – as chemotherapeutic agents can be cardiotoxic.
Management (AML focused):