Bruised
Blood & Lymphoreticular System
0
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P4_F1.jpg"}},{"insert":"\n\n"},{"insert":"It is an early start, and you have a full day of appointments planned. You are about to take the first sip of your morning coffee when you notice that you are running late.\n\nYou take a deep breath and ask for the next patient to be called in.\n"}]}
1
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P4_F2.jpg"}},{"insert":"\n\n"},{"insert":"In walks a young woman - Sophia, age 19 - accompanied by her mother, Deborah. Both sit down and offer a handshake. You introduce yourself and ask how you can help.\n"}]}
2
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P4_F3.jpg"}},{"insert":"\n\n"},{"insert":"Sophia begins, \u0022I haven\u0027t felt quite right for the last few days. I\u0027ve been really tired all the time, even though I\u0027ve been sleeping in. I feel weak and dizzy sometimes, like I\u0027ve been hit on the head.\u0022\n\nYou gesture to the couch and ask if you may examine her.\n"}]}
3
{"ops":[{"insert":"You record her height as 162cm and weight as 50kg; her BMI is therefore 19.\n\nShe is running a fever of 38\u02daC (100.4\u02daF). Her heart rate is 75bpm and blood pressure is 110\/75 mmHg.\n\nOn examination you find pallor, some mild bruising on multiple areas of her body and palpable lymphadenopathy of the submandibular, axillary, and inguinal nodes.\n\nYou ask if the enlarged nodes are ever painful or tender, and she replies in the negative.\n\nFurther examination reveals a slight enlargement of the spleen.\n"}]}
4
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P4_F5.jpg"}},{"insert":"\n\n"},{"insert":"Fearing something serious, you order a complete blood count and peripheral smear. The results are as follows:\n\nHemoglobin: 9g\/dL (11.0-18.0) \nPlatelets: 80,000\/mm3 (150,000-400,000)\nWBC: 13,000\/mm3 (4,600 -11,000)\nANC (absolute neutrophil count): 2000 cells\/\u03bcL (1500-8000)\n\nThe smear shows small blasts with clear cytoplasm and no granulation, nucleoli or Auer rods.\n"}]}
5
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P4_F6.jpg"}},{"insert":"\n\n"},{"insert":"Based on the findings on the smear, you make a provisional diagnosis of acute lymphoblastic leukemia and contact Sophia, requesting her to return to your office to discuss the results.\n\nAs you put the phone down, your colleague pokes his head in the door.\n\n\u0022Would you mind taking on one of the visiting medical students for a little while?\u0022 he asks, simultaneously reminding you that you owe him one.\n\nYou oblige, and ask the student to come in.\n"}]}
6
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P4_F7.jpg"}},{"insert":"\n\n"},{"insert":"The student greets you and shakes your hand, asking about your latest case. You explain it to him and he listens intently, scribbling notes all the while.\n\nHe pauses for a moment. \u0022Doctor, will you be performing a lumbar puncture to check for CNS involvement?\u0022\n"}]}
7
{"ops":[{"insert":"What will you say?\n"}]}
1. "No, that won't really be necessary at this point"
2. "Yes, I'm calling for one as we speak"
10
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9
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8
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