CLINICAL ABSTRACT

November 25, 2019

This is a case of patient SALTING, JADINE FRIGILLANA, 13/F, from SAN BENITO SUR , ARINGAY, LA
UNION admitted November 15, 2019 who came in due to leg cramps. History of present illness started 6
days prior to consult, patient had leg cramps, associated with easy fatigabiity, joint pain and body
weakness, consult is done where she was prescribed with Ferrous Fumarate 60mg/400mg/cap OD and
Ibuprofen 200mg/tab as needed for pain. Persistence of signs and symptoms, now with appearance of
rashes, nonpruritic at the neck and at the back area and feeling feverish prompted consult. Pertinent
Physical examination upon admission is Pale conjunctivae, (+) cervical lymphadenopathy, Palpable liver
and spleen, (+) peticheal rash on neck and back. Initially managed as a case of Systemic Autoimmine
Disease, Lymphoproliferative neoplasm t/c Acute Lymphoblastic Leukemia vs NHL.
Work ups was done which showed persistent Thrombocytopenia (from 24 x 10 9/L, latest 20 x
109/L), persistent Anemia (from 92mg/dl, latest 82mg/dl), leukocytosis on admission to leukopenia
currently (2.6 x 109/L), Normal Reticulocyte Count (1.02), Elevated SGOT at 74 and normal SGPT at 25,
ESR elevated at 125, Positive Coomb’s test: Direct (+1), Normal Thyroid function test, PBS showed
immature lymphocytes: 32% undifferentiated blasts:8% and repeat PBS showed persistence of medium
sized mononucleated cells with fine chromatin, 1-2nucleoli and thin rim of basophilic cytoplasm
appearing as lymphoblasts with occasional myeloblasts and platelets are severely decreased. Negative
ANA IMF 1:<40. Initial chest xray (11/15/2019) revealed essentially normal to current CXR (11/23/2019)
result of marked progression of the Bilateral lung opacities obscuring the left hemidiaphragm and heart
shadow. Abdominal UTZ (11/17/2019)revealed Hepatosplenomegaly, Gallbladder biliary sludge, Minimal
abomino-pelvic ascites and repeat abdominal UTZ b(11/23/2019) Hepatospeenomegaly

Patient was then started with

1. Methylprednisolone 16mg (Mepresone) 1 tab, 2x a day and shifted to Hydrocortisone 100mg IV
now then q12h on the second day of admission and shifted at 6 th day of admission to Prednisone
(30mg/day) 20mg/tab at 1 tab post BF and 1/2 tab
2. Currently on Paracetamol 500mg 1 tab q4 hrs for fever
3. Dexamethasone pulse therapy
4. Omeprazole 40mg (Risek) 1 cap OD prebreakfast shifted to Omeprazole IV to 40mg PO 30mins
prebreakfast
5. Rebamipide 100mg (Mucosta) 1 tab TID premeals
6. Allopurinol 100mg 1 cap BID
7. NaHCO3 650 1 tab OD
8. Ceftriaxone + Sulbactam 1.5gms OD increased on the 2 nd day to Ceftriaxone+Sulbactam ( Zeftrax)
1.5gms to q12hrs and shifted on the 4 th day of admission to to Piperacillin-Sulbactam 4.5g
(Tambacin) IV q8h (Day 6)
9. Tramadol 50mg IV q8hrs PRN for muscle and abdominal pain shifted to Tramadol 50 mg + 9 cc
ivf slow iv q 6 hours prn for severe pain only
10. Currently on Tranexamic acid to 500mg IV q8 hrs as PRN for active bleeding
11. Azithromycin 500 mg 1 tab OD (Day 7 completed)
12. Levodropropizine 10 mL TID
13. Given Furosemide 20mg IV once (11/18/2019) for appearance of pitting edema and Bilateral
effusion and shifted to Furosemide 20mg IV OD (11/19/2019) for persistent (+) bipedal edema
and was hold on 11/22/2019
 14. Salbutamol + ipratropium nebulization every 8 hours (11/20/2019) for complain of dyspnea
15. PreBT meds (30mins prior): Diphenhydramine 25mg I, Paracetamol 300mg IV
16. Lactulose 20 cc OD HS (11/21/2019) for absence of BM for 3 days and Bisacodyl suppository
(Dulcolax) 2 suppositories per rectum three times a day started at 11/23/2019
17. Clonidine 75mcg 1 tab SL as PRN for BP >140/90 (11/21/2019) for 1 episode of hypertension at
140/90
18. Domperidone 10mg 1 tab TID
19. KCl 1 tab TID x 6 doses fo K of 3.5 (11/21/2019)
20. Naproxen 550mg 1 tab 2x a day on full stomach (11/22/2019) discontinued 11/24/2019
21. Vancomycin 1gm IV q12hrs (11/23/2019) 2 doses given only
22. Mg 250mg 1 tab q6 hrs x 4 doses for Mg of 1.18 (11/24/2019)

Patient was transfused with total of 2 U PRBC and 16 U Platelet Concentration.

LN and BM core biopsy done on 11/19/2019 with BONE MARROW IMPRINTS revealed Hypercellular
marrow with bilineage hematopoiesia, Megakaryocytes are not well seen, Note of abundance and small,
large sized mononucleated celss with fine chromatin with 1-2 nucleoli with thin rim and deeply
basophilic cytoplasm. Still awaiting for result of flow cytometry and HP of BM and LN

On the 10th day of admission, patient is more active and conversant with decreased febrile episodes, (-)
bleeding episodes. Patient relatives requested for discharged hence discharged with final diagnosis of
SEPSIS SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA, MODERATE RISK; ACUTE
LYMPHOPROLIFERATIVE NEOPLASM SECONDARY TO ACUTE LYMPHOBLASTIC LEUKEMIA

Dr. AILA VELASCO .

RESIDENT IN CHARGE