WELCOME
A 60-year-old female presented with fever and weakness
Dr. Khadiza Akter
MD Resident (Phase-A)
Green Unit
Department of Haematology
BSMMU
Particulars of the patient
Presenting Complaints
History of present illness
According to the statement of the patient, she was reasonably well 2 months back. Then she developed irregular on and off fever which lasted for 3-4 days, twice or thrice episodes in a month. Fever was low grade intermittent in nature, highest temperature was recorded 100°F. Fever was not associated with chills & rigor, night sweat & was subsided after taking antipyretic.
History of present illness (cont’d..)
On query she gave history of generalized weakness for the same duration. Weakness was associated with palpitation & dizziness, for which she couldn’t perform her daily activities properly.
For the last 1 month she noticed multiple ecchymosis in front and back of the chest and legs.
She also developed a swelling in the lower part of the left arm for 7 days which was painful and for this reason there was difficulties in movement of the left elbow joint.
History of present illness (cont’d..)
There was no history of headache, blurring of vision, , cough, hemoptysis & contact with TB patient, abdominal pain, burning micturition.
Her bowel & bladder habit is normal.
History of Past illness
She is a known case of Diabetes mellitus for 6 years and Hypothyroidism for 1 year
Treatment History
- Tab. Secrin (1mg)
- Tab. Thyrox (50 mcg)
Family History
Personal History:
No history of betel nut chewing, smoking or taking alcohol.
Immunization history
Menstrual history
Socioeconomic History
Physical examination
General Examination
General Examination(cont’d…)
General Examination(cont’d…)
non pruritic, not palpable non tender and not blanch on pressure.
Systemic Examination
Musculoskeletal system
- There is a swelling in the lower 1/3 of the left arm
- Approx.. 5 cm * 1.5 cm in diameter
- Skin Color: Red
- Local Temperature: Raised
- Tenderness: Grade – III tenderness
- Consistency: Firm. Not fixed with overlying skin or underlying structure
- Elbow joint: Restricted both active and passive movement
Abdomen
Inspection:
Abdomen(cont’d)…
Palpation:
Liver- not palpable
Spleen- not enlarged
Kidneys- not ballotable
Abdomen(cont’d)…
Percussion:
Upper border of the liver dullness: right 5th intercostal space along the mid- clavicular line
No evidence of ascites (no fluid thrill, no shifting dullness).
Auscultation:
Other system
Cardio-Vascular system
Respiratory system Reveals normal findings
Nervous system
Musculoskeletal system
Salient Feature
Mrs. Shanti Begum, 60 yrs. Old housewife, diabetic,hypothyroid, normotensive hailing from madaripur presented with low grade intermittent fever for 2 months, twice or thrice episodes in a month. Each episode lasted for 3-4 days. Highest temperature was recorded 100°F & was not associated with chills & rigor, night sweat & was subsided after taking antipyretic.
She also presented with generalized weakness, palpitation & dizziness which are more even on mild activity.
Salient Feature(cont’d)…
For the last 1 month, she noticed multiple ecchymosis in different parts of the body including front, back of the chest and legs.
She also developed a painful swelling in the lower part of the left arm for 7 days with impairment of flexion of the left elbow joint.
There was no history of taking any drugs or exposure to radiation or chemicals. Her bowel & bladder habits are normal.
There is no family history of bleeding disorder.
Salient Feature(cont’d)…
On general examination, patient is moderately anaemic, all vitals are normal, multiple ecchymosis in front, back of the chest and legs which are of variable size and shape, painless,nonpalpable and do not blanch on pressure.
On systemic examination, there is a swelling in the lower 1/3 of the left arm approx. 5 cm * 1.5 cm in diameter which is firm, tender with impairment of flexion of the left elbow joint.
���What will be the diagnosis ?��?????
Investigations (Blood)
CBC with ESR | 30/03/2022 | 4/4/2022 | 10/04/2022 |
Hb | 8.8 gm/dl | 7gm/dl | 7.4gm/dl |
ESR | 50 mm in 1st hr | 25 mm in 1st hr | 20 mm in 1st hr |
RBC | 3,40,000 | 2,69,000 | 2,82,000 |
Platelet | 50,000 | 1,10,000 | 50,000 |
TC | 5,500% | 3,300 | 3,500 |
Neutrophil | 10% | 24% | 25% |
Lymphocyte | 45% | 70% | 70% |
Monocyte | 10% | 4% | 4% |
Eosinophil | 0% | 2% | 1% |
Basophil | 0% | 0% | 0% |
Blast Cell | 35% | - | - |
Investigations(cont’d…)
APTT | 31.90 seconds | 4/4/2022 |
Fasting B. glucose | 10 mmol/L | 3/4/2022 |
2 Hrs. after brakefast | 8.5 mmol/L | 3/4/2022 |
HbA1C | 4.3% | 3/4/2022 |
TSH | 0.36 µIU/mL | 3/4/2022 |
FT3 | 1.77 pcg/mL | 3/4/2022 |
FT4 | 0.71 ngm/dL | 3/4/2022 |
S. Albumin | 1.1g/L | 13/04/2022 |
S. bilirubin | 0.3mg/dl | 10/04/2022 |
HBsAg, Anti HCV | Negative | 21/03/2022 |
HIV | Negative | 21/03/2022 |
Investigations(cont’d…)
S. Creatinine | 0.81 mg/dl | 10/04/2022 |
S.Calcium | 6.9 mg/dl | 10/04/2022 |
S. Electrolytes: Na | 132 mmol/l | 11/04/2022 |
K | 4.9mmol/L | 11/04/2022 |
Cl- | 102 mmol/L | 11/04/2022 |
T-CO2 | 15.3mmol/L | 11/04/2022 |
SGPT | 22 U/L | 10/04/2022 |
RT-PCR for Covid-19 | Negative | 02/04/2022 |
Bone Marrow examination report
Date: 22/03/22
Comment: Suggestive of Acute Myeloid Leukemia (AML)
Flowcytometry
Flowcytometry(cont’d)…
Flowcytometry(cont’d)…
Echocardiography(30/03/22)
X-Ray left arm Both view
Comment: Normal Study (date: 09/04/22)
Confirmatory Diagnosis
Acute Myeloid Leukemia (AML)
Thank You