M-3 Case Study L.L., a 9-year-old male, was brought to his dentist for a regular preschool check-up.

Previous dental visits had been routine except for 2 years ago, when L.L. missed one appointment because of chicken pox. The dentist and the boy's mother were having a chatty conversation when L.L.'s mother stated that her son had recently stopped showing interest in sports and complained of fatigue. During the dental examination, the dentist noted gingival bleeding whenever the tissue was lightly probed. Three nontender lymph nodes were palpable in the submandibular nodes; no other abnormalities were noted. The dentist advised the mother to take L.L. to the medical clinic next door. The physical examination by the nurse practitioner showed L.L.'s skin to be pale with ecchymoses and petechiae of the trunk. The spleen and liver were not palpable, and the remaining examination was unremarkable. A sample of blood was withdrawn. The CBC revealed the following:

L.Ls results: Hemoglobin = 9.2 g/dl Hematocrit = 30% RBCs = 3 x lOVmm3 WBCs = 16 x lOYmm3 Neutrophils = 8 x 103/rnm3 Basophils = 250/mm3 Eosinophils = 445/mm3 Monocytes = 1900/mm3 Lymphocytes = 4500/mm3 Blastocysts = much higher than normal Platelets = 30 x 103/mm3

Normal Values: 14-18 g/dl 40-50% 4.7 6.1 milli/mcl 4500- 10000 1950- 8400/ul 12- 200 12 to 760/ul 24 to 960/ul 660- 4600

Result low low low high increasing to high high in range high increasing to high

150,000 - 350,000/mL

low

1.

Considering the examination and the CBC results, what would the nurse practitioner likely do?

As the NP for this patient I would immediately focus on the returned labs and symptoms noted in exam. Upon physical exam the skin was noted as pale with petechiae and ecchymoses. The gums began to bleed with minor assessment trauma indications of abnormalities. The lab results are indicative of a several infection possibilities: decreased RBC- due to abnormal loss of erythrocytes, abnormal destruction of erythrocytes or bone marrow suppression. Decreased Hematocrit due to the decreased number of RBC. Decreased Hemoglobin indicates anemia, increased WBCs indicate infection. Therefore, the main indicating factor would be the presence of blastocysts in peripheral blood, this factor is leading to bone marrow dysfunction. In ALL, stem cells turn into lymphoblast (leukemia cells) and they do not mature into lymphocytes. These immature cells are unable to fight infection. The leukemia cells increase in number as they travel through the blood and eventually into the marrow. This taking over effect depletes the RBC, WBC and platelets leading to anemia (fatigue), easy bleeding (gingival bleeding and the petechia and ecchymosis) and infection (increased WBC). Blastocysts much higher than normal is a big factor. I would educate the family on my findings and refer L.L to a pediatric oncologist for extensive labs, diagnostics and treatment. Such test would consist of Bone Marrow Aspiration and biopsy, Lumbar puncture, and an UL of the kidneys, liver and spleen. I would explain the importance of the test needed in order to determine the type and subtype of leukemia and the effects of fast and intense treating once diagnosed. Blood Smear to check the abnormal number of the different blood cell types, and detect the changes in the way they look (ACS, 2013).

**If within my scope I would complete a medical history asking how long symptoms have been going on and if there is a family history of cancer or any other disease and order a Blood Smear to check the abnormal number of the different blood cell types, and detect the changes in the way they look (www.cancer.org). I would speak with the mother and father (if present) and explain my suspicions, going over the lab work we have, compared to the results of exam (loss of interest, fatigue, gingival bleeding, three nontender lymph nodes in the submandibular nodes, pale skin, ecchymoses and petechiae of the trunk, spleen and liver not palpable) and expressing my concern to pursue this intensely to determine if suspicions are correct

and if so begin immediate treatment. I would explain the importance of the test needed in order to determine the type and subtype of leukemia and the effects of fast and intense treating once diagnosed. As soon as approval has been given I would have clerical call lab to see if there is enough blood from earlier to perform a PT/ INR, PTT and complete a type and screen in case blood is needed immediately. I would order a Bone Marrow Aspiration and biopsy, Lumbar puncture, and an UL of the kidneys, liver and spleen. Knowing a cytochemistry lab only show certain types of leukemia; I would order phenotyping by flow cytometry this test cells from bone marrow, lymph nodes and blood samples to determine exact type of leukemia (labtestonline.org). Complete a medical history asking how long symptoms have been going on and if there is a family history of cancer or any other disease. In ALL, stem cells turn into lymphoblast (leukemia cells) and they do not mature into lymphocytes. These immature cells are unable to fight infection. The leukemia cells increase in number as they travel through the blood and eventually into the marrow. This taking over effect depletes the RBC, WBC and platelets leading to anemia (fatigue), easy bleeding (gingival bleeding and the petechia and ecchymosis) and infection (increased WBC). The lab results are indicative of a several infection possibilities: decreased RBC- due to abnormal loss of erythrocytes, abnormal destruction of erythrocytes or bone marrow suppression. Decreased Hematocrit due to the decreased number of RBC. Decreased Hemoglobin indicates anemia, increased WBCs indicate infection. Therefore, the main indicating factor would be the presence of blastocysts in peripheral blood, this factor is highly geared at bone marrow dysfunction. 2. Which one of the lab values is most significant in diagnosing this disease? WBCsBlastocysts being much higher than normal- shows bone marrow dysfunction. Are nontender lymph nodes relevant to the diagnosis, if yes, then why? A hard, nontender, nonmoveable lymph node may lead to the detection of a cancer that has spread to that node. Symptoms coming from another infection that make the lymph node swelling may be more significant and clinically relevant than the lymph node swelling alone. Symptoms like weight loss, fever, bleeding or knowing of local infections festered hair, sore throat or inner ear infection can lead to the cause of the lymph node swelling.

3.

4.

Identify at least 8 signs and symptoms in the case study that support the diagnosis.

ANS: 1. stopped showing interest 2. complaint of fatigue 3. gingival bleeding to light trauma 4. pale skin 5. petechial and 6. ecchymosis on trunk 7. 3 non-tender lymph in the submandibular palpable 8. Spleen and liver not palpable

5.

Identify at least 3 relevant signs and or symptoms of the disease that were not mentioned in this case study and discuss why they are relevant. Shortness of breath- The depletion of oxygen carrying RBC will interfere with organs receiving the amount needed to sustain. If ALL spreads to the chest area this can cause fluid build up. The T-cell subtype of ALL affects a small organ (thymus) in the middle of the chest right behind the sternum but in front of the trachea. This organ becoming enlarged, applies pressure and when placed on the trachea can cause issues with breathing, and coughing fits (www.cancer.org). The thymus being enlarged will also cause pressure on the Superior Vena Cava, this will cause the blood to back up into the veins. The blood being forced back can cause edema to the face, arms, neck and chest area. Headaches, dizziness and a change in consciousness arises with this onset of SVC Syndrome.

Reference: American Cancer Society (ACS). (2013). http://www.cancer.org St. Jude. (2012). http://www.stjude.org.

1)Discuss the two main types of Chronic Leukemia in comparison with the Acute Leukemias. 2)What is the Phenotyping Cyto Flow used for and why is it important? 3) Explain the leukocytic alterations of:

a) Eosinophilia b) Cytoblasts 4) Explain the Philadelphia chromosome and which leukemia it is found. The article I read was Clinical and laboratory features of leukemias at the time of diagnosis: An analysis of 1,004 consecutive patients in the American Journal of Hematology. This article discussed how the basic criteria for signs and symptoms, not the new diagnostic test results, that students have learned about for years in their textbooks still represent what Dr. need to diagnose leukemia. The new diagnostic test available are used but fall to the way side when symptoms for ALL show during diagnosis, The most frequent symptoms in AL patients were fatigue and weakness, followed by pain and dyspnea (Racil et al.; 2011. p. 800). Patients that were monitored during the first medical visit noting the symptoms that show more frequent were the infections at number one proceeded with bleeding and labored breathing, (Racil et al.; 2011). The report goes on to explain the incidental diagnosis of leukemias due to the frequently performed labs than actually knowing, or using any diagnostic test. The article discusses how, A finding of leukocytosis immediately triggers a referral to a hematologist, (Racil et al.; 2011. p. 802). The authors of the article have placed together a chart I am attaching that show the time allotted from symptom to final diagnosis with the major physical signs relating to the WHO classification. In summary, what I read seemed to flow with the summation of nothing is better than the signs and symptoms to red flag a patient in need of immediate medical attention. When the patient comes into the doctor office and list off the symptoms, only that patient can verify if that is a true statement being made-no one knows better than the one making statement. Newer test can be used but if one will rely on the Nursing knowledge taught in school that has been imbedded into our souls we will know when something is going on and needs further treatment. Some of the patients were sent around before being sent to a specialist or any type of diagnosis was made. This prolongation enhances the chance of metastasis, failure of therapy and increased time and money spent. We are fully equipped to rely on the foundations of knowledge we carry with us, and have since that first semester of our bachelor degree. Reference: Racil, Z., Buresova, L., Brejcha, M., Prochazkova, J., Zounar, R., Timilsina, S., ... Toskova, M. (2011). Clinical and laboratory features of leukemias at the time of diagnosis: An analysis of 1,004 consecutive patients. American Journal of Hematology, 86(9), 800-803. http://dx.doi.org/10.1002/ajh.22100