HEMATOLOGY WARD

CASES PRESENTATION
MONDAY 25TH MARCH 2024
WARD CASES
• WARD STATE FROM FRIDAY 22ND MARCH 2024
• 3 PATIENTS
• 0 DISCHARGES
• 0 MORTALITIES
• 1 NEW ADMISSION
J.B
• 60 YEAR OLD FEMALE
• BEING MANAGED AS A CASE OF:
• CLL (BINET STAGE C)
• NEWLY DIAGNOSED RVI
• DVT OF RIGHT LEG SEC IMMOBILTY, ?DISSEMINATED KOCHS/CLL
• ? PNEUMOCYSTIS JIROVECI PNEUMONIA
• OLD STROKE
• REFFERED TO HEMATOLOGY BY PS TEAM O/A SEVERE ANEMIA,
LYMPHADENOPATHY
• SINCE ADMISSION, A BLOOD FILM COMMENT REPORT CONFIRMED
CHRONIC LYMPHOCYTIC LEUKEMIA
• PATIENT HAS BEEN STARTED ON SEPTRIN AND PREDNISOLONE
• PATIENT HAS BEEN TRANSFUSED 4 UNITS OF BLOOD WHILE ON
ADMISSION
INVESTIGATIONS
• FBC
DATE HB MCV MCH WBC NEUT LYMPH PLT
08/03/24 2.6 106.3 32.5 369.65 1.68 334.09 24
17/03/24 5.2 88.1 30.2 397.41 4.27 375.55 25
20/03/24 5.2 98.5 26.5 310.03 1.08 249.70 19
21/03/24 6.0 94.6 24.9 355.65 1.51 289.09 23
INVESTIGATIONS
• BUE/CR
DATE NA K CL UREA CR EGFR
08/03/24 142.0 3.0 105.0 2.3 57 112
INVESTIGATIONS
• LFT
DATE T. BIL D.BIL AST ALT ALP GGT T.PROTEIN ALBUMIN
08/03/24 7.9 4.3 33 17 137 43 60 33
INVESTIGATIONS
• ESR – 159 H
• SERUM CA(ADJUSTED) – 2.4
• LDH – 296 H
• URIC ACID – 312
• PHOSPHORUS – 0.52 L
• VIRAL SCREEN
• HBV – NON REACTIVE
• HCV – NON REACTIVE
• HIV – REACTIVE
INVESTIGATIONS
• ABDOMINAL ULTRASOUND IMPRESSION:
• DIFFUSELY ECHOGENIC BUT NORMAL SIZED LIVER: HEPATIC STEATOSIS,
• ECHOGENIC BUT NORMAL SIZED KIDNEYS: RENAL PARENCHYMAL DISEASE,
• SPLENOMEGALY, MINIMAL ASCITES,
• MULTPLE DEGENRATIVE UTERINE MYOMATA AND
• MILD RIGHT PLEURAL EFFUSION
• DOPPLER OF THE RIGHT LEG: LONG SEGMENT ECHOGENIC
THROMBUS SEEN
MEDICATIONS
• TB ALLLUPURINOL 300MG OD
• SC CLEXANE 80MG BD
• TAB SEPTRIN 1680MG TDS
• PREDNISOLONE 40MG BD FOR 5/7 THEN TO TAPER TO 40MG
OD FOR 5/7, THEN 20MG OD
• TAB OMEPRAZOLE 40MG BD
CURRENT ASSESMENT
• C/O:NO NEW COMPLAINTS
• O/E:
• VITALS: SP02 96% ON ORA, RR: 20 CPM, PR: 75 BPM, BP:
115/61MMHG, TEMP:36.3*C
• ELDERLY WOMAN, LOOKS CHRONICALLY ILL, P+++, J-, AFEBRILE,
HYDRATION SATISFACTORY, BIPEDAL EDEMA (RIGHT 29CM > LEFT 26
CM, 10CM FROM TIBIAL TUBEROSITY), CLUBBING+,
LYMPHADENOPATHY+(GENERALISED IN AXILLA AND CERVICAL
REGION, NON TENDER , MOBILE, LARGEST 2CM)
CURRENT ASSESMENT
• CVS: APEX: 6LICS, AAL, HS I AND II +, M+(PANSYSTOLIC MURMUR)
• RESP: VF INCREASED IN RIGHT UPPER AND MIDDLE LUNG ZONES,
COARSE CREPS IN THE RIGHT UPPER LUNG ZONE, AE REDUCED IN THE
RIGHT MIDDLE AND LOWER ZONES, BS VESICULAR ON THE LEFT
• ABD: FULL, SOFT, MWR, NON TENDER, L+, S+(5CM BELOW COSTAL
MARGIN), ASCITES+
• CNS: CONSCIOUS AND ALERT, GROSSLY INTACT
UPDATES
• PATIENT TO COMPLETE 10-14 DAYS OF SEPTRIN BEFORE
STARTING ARVS
• TO REPEAT FBC TODAY AT REFERENCE LAB AS FAMILY
MEMBERS WERE NOT AROUND DURING REVIEW
D.O
• 54 YEAR OLD FEMALE
• BEING MANAGED AS A CASE OF:
• Relapsed MM with parapnemonic effusion
• PATIENT REPORTED TO HER REGULAR REVIEW AT THE HEMATOLOGY DAY
CARE WITH COMPLAINTS OF DIFFICULTY IN BREATHING AND A SWOLLEN
LEFT UPPER ARM
• SHE ALSO HAD DYSPNOEA ON EXERTION.
• O/E AT THE DAY CARE SHE HAD LOW OXYGEN SATURATIONS OF 91 AND
WAS THEN ADMITTED TO THE WARD ON SUSPECTION OF PE AND DVT OF
THE LEFT UPPER ARM
• WHILST ON ADMISSION, SHE WAS PUT ON OXYGEN VIA NASAL PRONGS
• A DOPPLER OF THE LEFT UPPER ARM RULED OUT A DVT
• CTPA REPORT R/O PE
• A CXR CONFIRMED A PLEURAL EFFUSION ON THE LEFT SIDE
• ECG DONE WAS NORMAL
• PATIENT HAS COMPLETED 7 DAYS OF ANTIBIOTICS
• PLEURAL EFFUSION WAS TAPPED BY RESPIRATORY TEAM UNDER
ULTRASOUND GUIDANCE AND SAMPLES WERE SENT FOR ANALYSIS
• A THORACOCENTESIS OF THE LEFT PLEURAL EFFUSION DRAINED 1L
OF HEMORRHAGIC FLUID
• SAMPLES FROM BIOPSY OF ANTERIOR CHEST MASS WERE
SENT FOR ANALYSIS
• THERAPY HISTORY: SHE COMPLETED 6CYCLES OF VAD IN 2020 AND
RELAPSED AND WAS ON MAINTENANCE THERAPY WITH MELPHALAN
AND PREDINISOLONE
• SHE WAS THEN PUT ON THALIDOMIDE FOR 8 MONTHS
• SHE RESTARTED AND COMPLETED 3 CYCLES OF VAD IN 2023
• SHE WAS STARTED ON BCD ON FRIDAY 22ND MARCH
MEDICATIONS
• UFH 5000IU
• TB AMLODIPINE 10MG OD
• TB BISOPROLOL 5MG OD
• CHEMOTHERAPY- BCD
CURRENT ASSESSMENT
• NO NEW COMPLAINTS, PATIENT FEELS BETTER HOWEVER SHE STILL HAS
DYSPNOEA ON EXERTION
• O/E: VITALS: SP02 92% ORA, RR: 22 CPM, PR: 95 BPM, BP: 125/95
MMHG, TEMP:36.1*C
• A MIDDLE AGED WOMAN, RESP DISTRESS-,P-,J-,AFEBRILE, HYDRATION
STATUS FAIR, PEDAL EDEMA-, PLASTER ON ANTERIOR CHEST WALL
MASS
• RESP: AE REDUCED BILATERALLY, BS VESICULAR
• ABD: OBESE, SOFT, MWR, NO ORGANOMEGALY
• CNS: CONSCIOUS AND ALERT, GROSSLY INTACT
INVESTIGATIONS
• FBC
DATE HB MCV MCH WBC NEUT LYMPH PLT
12/03/24 8.5 - - 6.86 - - 46
15/03/24 8 82.5 28.6 8.47 2.32 3.27 53
17/03/24 7.5 82.7 29 9.73 3.33 3.62 42
20/03/24 8.7 79.6 28.20 13.69 4.38 4.47 45
INVESTIGATIONS
• BUE/CR
DATE NA K CL UREA CR EGFR
14/03/24 140.0 3.4 108.0 7.5 190 25
18/03/24 141.90 4 108.10 8.25 261.5 13
23/03/24 136.40 3.70 102 10.43 249.40 29.22
INVESTIGATIONS
• CTPA REPORT:
• No intrapulmonary filling defects suggestive of pulmonary embolism (PE) seen.
• Moderate bilateral pleural effusions with upper lobe pleural thickenings.
• Left lower lobe opacity with air-bronchogram-could be consolidation or lung
collapse.
• Large soft tissue mass in the anterior/superior mediastinum displacing the vessels,
trachea and esophagus posteriorly without infiltration.
• Enlarged right axillary lymph node.
• Findings are suggestive of Lymphoma DDx: Thymic malignancy.
• Well-defined lytic lesion with sclerotic margins in the posterior part of T8 likely a
benign bone lesion-Follow up however suggested.
UPDATE
• AWAITING RESPIRATORY TEAM’S INPUT ON PLEURAL EFFUSION
C.B
• 67 YEAR OLD FEMALE
• BEING MANAGED AS A CASE OF:
• MULTIPLE MYELOMA IN REMISSION WITH HYDRO-PNEUMOTHORAX
• ESRD SEC HTN/DM ON RRT(2X WEEKLY DIALYSIS)
• REFFERED FROM NYAHO HOSPITAL AFTER PRESENTING THERE WITH
HX OF DYSPNEA FOR WHICH A CHEST TUBE WAS PASSED
• SUBSEQUENTLY NOTED TO HAVE A HYDRO-PNEUMOTHORAX ON THE
RT POST CHEST TUBE REMOVAL
• SINCE ADMISSION, TUBE THORACOSTOMY DONE AND STILL
DRAINING SEROUS FLUID WITH IMPROVEMENT IN DYSPNEA
• RENAL TEAM SWITCHED ANTIBIOTICS TO ROCEPHIN AND
AZITHROMYCIN ON MONDAY 18TH MARCH
• CHEMOTHERAPY ON HOLD UNTIL PATIENT IS CLEAR OF INFECTION
CURRENT ASSESSMENT
• NO NEW COMPLAINTS

• BONE PAIN-, ASYMPTOMATIC OF ANEMIA,

• O/E- ELDERLY WOMAN, STABLE, P+, J-, AFEBRILE,

HYDRATION SATISFACTORY, PEDAL EDEMA(RT>LT)

• CVS- PR- 90 BPM, RGV, BP- 147/64 MMHG, HIS&II+, M-

CURRENT ASSESSMENT
• RESP- RR-22CPM, SPO2 – 94 ORA, PN STONY DULL IN RT
LOWER ZONE, AE REDUCED ON THE RT(ABSENT IN LOWER
ZONE), BS VESICULAR, HARSH TRANSMITTED SOUNDS IN RT
UPPER ZONE, CHEST TUBE IN SITU DRAINING 200MLS OF
SEROUS FLUID

• ABD- FULL, MWR, SOFT, NO ORGANOMEGALY

• CNS- CONSCIOUS HOWEVER CONFUSED, NO FOCAL

NEUROLOGICAL DEFICITS
•
INVESTIGATIONS
• SERUM FREE LIGHT CHAINS(08/03/24)
• S-KAPPA FREE LIGHT CHAINS – 204 H
• S-LAMBDA FREE LIGHT CHAINS – 79.20 H
• KAPPA/LAMBDA RATIO – 2.58

• SERUM PROTEIN ELECTROPHORESIS(08/03/24)

• M COMPONENT - 0
INVESTIGATIONS
• FBC
DATE HB MCV MCH WBC NEUT LYMPH PLT
01/03/24 6.8 80.2 26.5 16.68 13.16 1.96 117
04/03/24 8.8 74.5 24.5 5.41 3.067 1.705 141
06/03/24 8.8 74.7 24.1 7.75 5.313 1.737 204
11/03/24 10 74.7 25.7 10.49 8.930 1 219
24/03/24 9.3 72 26 23.96 21.003 1.744 254
INVESTIGATIONS
• BUE/CR
DATE NA K CL UREA CR EGFR
06/03/24 132 3.5 - 7.5 202 21
24/03/24 130 4.8 - 12.7 303.4 15
• BLOOD CULTURE(13/03/24): NO GROWTH
• PROCALCITONIN(04/03/24): 73.76 (<0.05)
• DOPPLER OF RIGHT LOWER LIMB (06/03/24): NO CLOT SEEN
• CULTURE OF NECK LINE CATHETER TIP(23/03/24): NO GROWTH
• SERUM CA ADJUSTED(24/03/24): 2.12
• CRP(24/03/24): >200 (<10)
• TSH(24/03/24): 6.96 (0.50-4.20)
• ESR(24/03/24): 45 (4-7)
UPDATES
• AWATING RENAL TEAM DECISION ON REPEATING PROCALCITONIN
• TO START MAINTENANCE THERAPY ONCE STABLE
E.H
• 24 YEAR OLD FEMALE
• BEING MANAGED AS A CA
• AML IN RELAPSE
• ?INTRACRANIAL BLEED
• PATIENT PRESENTED TO THE ER WITH BLEEDING FROM MOUTH OF 1
DAY DURATION AND BLOODY VOMITUS OF 1 DAY DURATION
• FURTHER QUESTIONING REVEALED PATIENT WAS ALSO BLEEDING PER
VAGINUM
• SINCE BEING ON ADMISSION, SHE HAS CONTINUED TO ACTIVELY
BLEED
• SHE HAS BEEN TRANSFUSED WITH 2 UNITS OF CRCS AND 4 UNITS OF
PLATELETS
• SHE HAS BEEN STARTED ON TRANEXAMIC ACID 1G TDS
• PATIENT WAS ADMITTED LATE FRIDAY NIGHT HENCE HEMATOLOGY
FOLDER WAS NOT RETRIEVED AND THERE ISN’T A LOT OF
INFORMATION ON THE LHIMS
• SHE WAS DIAGNOSED WITH AML IN OCTOBER. 2023, WENT INTO
MORPHOLOGICAL REMISSION AS AT JANUARY 2024 AND DEFAULTED
POST REMISSION THERAPY AND PRESENTED IN FEBRUARY 2024 WITH
A RELAPSE OF AML
• HER LAST CHEMO SESSION WAS ON 11TH MARCH
• SHE IS CURRENTLY UNDERGOING PHYSIOTHERAPY AS SHE
EXPERIENCED FACIAL DEVIATION SOMETIME IN FEBRUARY
CURRENT ASSESSMENT
• C/O: UNABLE TO ELICIT
• O/E: A YOUNG WOMAN, LYING IN BED, RESTRAINED, LOOKS ACUTELY
UNWELL, PALE++, J(TINGE), NOT WARM TO TOUCH, NO PEDAL OEDEMA,
DROOLING SALIVA FROM MOUTH, HAS MULTIPLE STRIAE ON UPPER LIMBS
• CVS: PR: 130BPM, BP: 168/100 MMHG, PULSE IS WEAK, REGULAR, POOR
VOLUME, HS I AND II PRESENT, NO MURMURS
• RESP: SPO2: 98%, RR-24CPM, AE ADEQUATE BILATERALLY, BS VESICULAR, NO
ADDED SOUNDS
• ABD: FULL,SOFT,MWR, L-,S-,2K-, NO MASSES PALPABLE
• CNS: CONSCIOUS AND ALERT, GCS:13/15, NOT RESPONDING TO COMMANDS
INVESTIGATIONS
• FBC
DATE HB MCV MCH WBC NEUT LYMPH PLT
22/03/24 6.8 79.7 27.8 2.15 1.72 0.37 3
24/03/24 4.90 70.40 23.50 3.16 2.97 0.17 30
UPDATE
• TO DO HEAD CT TO INVESTIGATE INTRACRANIAL BLEED