Case Study #3 --

[JustPlainBill]

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So --cabinbuilder -- you can't play until the very end --- we discussed this one ---

HPI: 43 y/o presents with 1 week of sore throat as a new patient; states an episode of n/v one week ago, now has difficulty swallowing, slight muffled voice, tachycardia, fever to 101; Also notes blue spots on gums;

PMHx: none
PSurghx: none

medications: none

rapid strep positive

PE: thin WM, WD, NC/AT, NAD
ENT: nasal mucosa erythematous and congested, tonsils hypertrophied - left covered with mucoid exudate, right black and covered with mucoid exudate; 5mm blue/black lesion with irregular borders noted to right upper gums;
Chest: RRR, No M/R/G, CTAB

rest of exam is WNL --

And --- go ---

 

[cabinbuilder]

yes, dear.

 

[organdonor]

adequately vaccinated against measles?

 

[JustPlainBill]

Vaccines UTD ---

What's your working diagnosis and what other steps should you/would you take?

 

[SqEdSaint]

Check anti-rubeola antibodies igm and igg

 

[JustPlainBill]

Check anti-rubeola antibodies igm and igg

Good thought --

So -- patient received a gram of rocephin IM and was started on amoxil TID with a STAT ENT referral ---- and CBC was done as an after thought to establish a baseline white count to assist with therapy in 2 days at f/u ---

1 hour later, the lab tech drops the following on your desk ---

WBC -- 206
Hb -- 11.4
Hct -- 42
Platelets -- 35


and ....go

 

[VA Hopeful Dr]

Damn, so lymphocyte infiltration of the tonsil 2/2 leukemia?

 

[JustPlainBill]

Next move was STAT call to patient directing them immediately to the nearest ER -- personal call to ER physician giving them a heads up ---

Next morning -- received a call from Oncology -- patient admitted to bone marrow transplant service with 70% blasts and confirmed white count ---

Sorry the case wasn't more in depth but it all happened in about 2 hours on a Thursday evening and the CBC was an afterthought -- it was like God was prompting me to do it because I couldn't let it go --- reminded me to really walk into each room with an open mind and ask,"What's the worst this could be?" --- Looked like a simple peritonsillar abscess/necrotic tonsil -- when I first saw the leukocyte count I thought it was 20.6, noted the platelets and started to call but did a double take and saw the 206.....