NARRATIVE PATHOPHYSIOLOGY

On November 15, 2015, Patient XYZ was diagnosed with cancer of the
blood and the spongy tissue that produces the blood cells or also known as the
bone marrow, this diagnosis is also known as Acute Myelogenous Leukemia or
AML. This disease results from a defect in the hematopoietic stem cell that
differentiates into all myeloid cells: monocytes, granulocytes (neutrophils,
basophils, eosinophils), erythrocytes, and platelets. AML is also the most
common non-lymphocytic leukemia.
Certain risk factors influence the onset of the disease. Predisposing
factors would include age of five years old, the male gender and the family
history of colon and lung cancer which are considered to be some factors that
may cause the mutations in the hematopoietic stem cells in the bone marrow.
Other factors that could precipitate the disease include chemical exposure from
factories in the living areas of the patient and the lifestyle of regular intake of
processed food in the morning for breakfast which may cause the alterations in
genetic structure of stem cells.
The disease process starts with the alteration of the cells DNA structure
caused by the said factors. Proto-oncogenes or non cancerous cells, which are
responsible for normal metabolic processes in the body, are transformed to
oncogenes or cancerous cells - which are mutated genes which serve no
purpose in the body. There will be mutation of tumor suppressor genes which are
responsible for normal cell cycle and replication. This will lead to over production
of growth factors that are necessary for cellular growth and proliferation. Normal
cellular function will be altered such as transcription and translation process in
the cell cylce. Due to mutation, the cells error detection and correction
mechanism is dysfunctional causing production of more mutated cells. There will
be uncontrolled cell cycle and cell division due to the dysfunction in the
regulatory mechanisms. Since the bone marrow is the affected site, there will be
formation of neoplastic (cancerous) cells from mutated stem cells. In AML, the
affected precursor cells are the myeloblast which differentiates to monocytes,
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granulocytes (neutrophils, basophils, eosinophils), erythrocytes, and platelets.

Due to mutation, myeloblasts are in a state of differentiation arrest which
renders them unable to differentiate and mature. There will be mass production
of these myeloid precursors since they still have the ability to proliferate but in an
abnormal rate. These malignant cells are insensitive to apoptotic cell death or
programmed cell death. Accumulation of neoplastic cells occurs in the bone
marrow causing bone marrow expansion. Normal bone marrow cells will be
crowded by the malignant cells causing destruction and bone marrow
suppression. There will be alteration in hematopoiesis, the process of formation
of blood components. And then there will be formation of dysfunctional blood
components causing premature destruction and loss of their function.
During 30th of November 2015, he underwent a CBC test with given back
in alarming outcomes. There is a decrease in RBCs which read 2.19 X 1012/L, a
decrease of hemoglobin of 6.30 g/dL, an increase of leukocytes of 56.9 X 109/L,
and a severe decrease of platelets which read 29 X 109/L. With these results
doctors made out Anemia, An indication of infection, and Thrombocytopenia
Anemia is a condition where there is a decline in erythrocyte concentration
and with an accompanying decrease in hemoglobin levels. Erythrocytes and
hemoglobin are important in the transportation of nutrients and oxygen to tissues
and organs. Decreased levels would result to weakness, dyspnea, and palmar
and peripheral pallor due to low oxygen levels needed for metabolic processes.
As treatment for the alarming decrease of Red Blood Cells in the blood, the
admitting physician ordered a whole blood transfusion of 296ml on the 30 th of
November. 30 minutes prior to transfusion the patient was administered
Diphenyhydramine hydrochloride (Benadryl) 12.5mg/5ml, 5ml. A couple minutes
after due to hypersensitivity from the blood transfusion, the temperature of
Patient XYZ went up to about 38-39 degrees Celcius and was administered PRN
PCM (Biogesic) 250mg/5ml, 4ml, Q4, PO to help lower down the temperature.
Thrombocytopenia is a result of decreased platelet count in the blood.
Platelets may also exhibit diminished ability to aggregate during blood clotting
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and are less adhesive. Platelets are responsible for blood clotting process in the
presence of injury to the skin and other membranes. Thus for treatment, Patient
XYZ was seen by the admitting physician and was ordered to undergo another
whole blood transfusion of 296ml on the 4 th of December.
Same as before, 30 minutes prior to transfusion the patient was
administered Diphenyhydramine hydrochloride (Benadryl) 12.5mg/5ml, 5ml. A
couple minutes after the patient experienced hypersensitivity again from the
blood transfusion, and the temperature went up to about 38-39 degrees Celcius.
Patient XYZ was then administered PRN PCM (Biogesic) 250mg/5ml, 4ml, Q4,
PO to help lower down the temperature.
As the white blood cells increase in the body, the doctors could tell that
this was an indication of infection that was currently present in the Patients body
as it is a natural body defense of humans to produce more leukocytes for
phagocytosis or the destruction of invading organisms.
As the AML disease continues, it begins to metastasize. There will be
continuous proliferation of malignant leukemic cells in the bone marrow. Damage
to surrounding blood vessels occurs due to overcrowding of malignant cells and
there will be entry into the circulation. These malignant cells could lodge to
different organs and invade normal cells. They could invade the lymph nodes,
spleen, and liver, and will cause lymphadenopathy, splenomegaly, and
hepatomegaly which would cause abdominal discomfort and distention.
During the course of AML, the patient develops Pneumonia and Acute oral
thrush or better known as Oral Candidiasis. This is supported by the influx of
WBC in the body as seen in the results of the CBC on November 30 th.
Several factors are considered factors that may have triggered the patient
to develop Pneumonia. The predisposing factors that are evident is the young
age of the patient, and the gender as males are more likely to develop the
disease. The Precipitating factors are then the immature immune systems and
the small airways of the child.
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Pneumonia first starts out as the virulent microorganism that has not been
specifically identified by the admitting physician yet, which would enter the nose
and pass down into the larynx continuing through the pharynx and trachea until it
reaches the airway and lung parenchyma and starts to affect it. As the infection
starts, airway damage and lung invasion occurs. For the airway damage, it then
infiltrated the bronchi lodging stimulations in the bronchioles causing the alveolar
to collapse which would then increase the pyrogen percentage in the body
ultimately leading to fever with the temperature of 38 to 39 degrees Celsius
which would then be medicated with Paracetamol 250mg/5ml 4ml Q4 PRN. On
the other hand, after the lung invasion, flattening of the epithelial cells would
occur leading to two circumstances first of which is the mucus and phlegm
production by the macrophages and leukocytes causing the patient to have
productive cough with hard and greenish coloured phlegm which was medicated
with Piperacillin-Tazobactam (Vigocid) 900 mg IV Drip, Q6, ANST (-)12 MN 6
AM 12 NN 6 PM and Clindamycin (Cleocin Pedia) 75mg/5, 5ml, PO, QID
8AM 12NN 4PM 8PM. The second of which is the decrease in the red
blood cells with the laboratory and diagnostics results of 2.84x1012/L causing
body malaise by the patient.
Oral Candidiasis starts with the predisposing factors of age of five years
old and the precipitating factors of a weakened immune system and antibiotic
therapy. First the normal flora of the mouth is disrupted with the CD4 cell count
dropping below 350 the microorganism Candida albican then causes an
overgrowth of yeast on the oral mucosa causing the desquamation of epithelial
cells thus leading to the accumulation of bacteria, keratin, and necrotic tissue.
Because of the disease oral mucosal lesions are found in the patients mouth
which are then treated with Nystatin (Mycostatin) Syrup (suspension) 1ml, Swish
and Swallow, TID 8AM 1PM 6PM.
During the course of treatment for all the diagnosiss the drugs that were
used to medicate had a side effect of Diarrhea which became one of the
problems. That drugs that induced the side effect were Piperacillin-Tazobactam
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(Vigocid), Nystatin (Mycostatin), and Clindamycin (Cleocin Pedia). This started by

drugs disrupting the normal flora in the intestines, increasing the number of the
flora around. This shift of normal levels directly leads to the development of
gastrointestinal problems. This then leads to the ineffective bowel movement and
activity of the patient leading to the decrease of absorption of fluids in the large
intestines thus soft stools were noted. The admitting physician was notified and
Patient XYZ was prescribed Racecadotril (Hidrasec) 10 mg sachet 1 sachet per
10 ml H20, PO, TID 8AM 1PM 6PM as well a s dietary supplement of Zinc
Sulfate Syrup (E-Zinc) 5ml PO OD 6pm to help replenish the lost nutrients in the
patient.

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