aml case study

8/13/2019 AML Case Study

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ANGELES UNIVERSITY FOUNDATION

GRADUATE SCHOOL

Master of Arts in Nursing

A Case Stud On

ACUTE MYELOGENOUS LEUKEMIA

!RESENTED TO

ANNA LYN M"!AANO# RN# MAN

!rofessor# Con$e%ts I

!resented &

E!IFANIA !" GOGOLIN# RN

MAN Student


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I. INTRODUCTION

The terms malignant and cancer!s descri"e cells that are gr#ing and

$rli%erating in a disrderl&' chatic %ashin. In ad!lts' cancer !s!all& cc!rs in the %rm

% a slid t!mr. In children' the mst %re(!ent t&$e % cancer is that % an immat!re cell

)ergr#th' r le!*emia +McCance , -e!ther'//01.

Ac!te m&elgen!s le!*emia +AML1 is res!lts %rm a de%ect %rm a

hemat$eitic stem cells that di%%erentiates int all m&elid cells2 mnc&tes'

gran!lc&tes +ne!tr$hils' "as$hils' esin$hils1' er&thrc&tes and $latelets +Smelt3er'

et al.' //01. AML cm$rises a$$r4imatel& 556 % the cases r le!*emia in childhd

in the United States' #ith a$$r4imatel& 0// children diagnsed #ith AML ann!all&.

Unli*e ALL' the incidence % AML is cnstant %rm "irth thr!gh!t the %irst 5/

&ears % li%e #ith a slight $ea* in late adlescence. Internatinall&' AML is mre

cmmnl& diagnsed in de)el$ed c!ntries. AML is als mre cmmn in men than in

#men. There is n *n#n relatinshi$ "et#een race and the incidence % AML. It #as

"ser)ed th!gh' that AML is mre cmmn in #hites than in ther $$!latins. The

di%%erence is e)en mre a$$arent in lder $atients. 7re)alence increases #ith age.

-#e)er' this disease a%%ects all age gr!$s +Seiter' //81.

The $rgnsis is highl& )aria"le. 7atient age ma& "e a %actr9 $atients #h are

&!nger ma& s!r)i)e %r : &ears r mre a%ter diagnsis % AML. -#e)er.' $atients #h

are lder r ha)e a mre !ndi%%erentiated %rm % AML tend t ha)e #rse $rgnsis.

7atients #ith s!$$rti)e care !s!all& s!r)i)e less than 5 &ear' #ith death !s!all& a res!lt

% in%ectin and hemrrhage +American Cancer Sciet&' //81.

AML can $resent #ith relati)e s!"tle' nns$eci%ic s&m$tms s!ch anre4ia'

malaise' irrita"ilit&' and #eight lss. As the disease $rgresses' the& $resent #ith signs

and s&m$tms assciated #ith the %ail!re % nrmal hemat$iesis' #hich res!lts %rm

the re$lacement % nrmal marr# cells "& malignant cells. The child ma& e4hi"it %atig!e

$allr' and decreased acti)it& d!e t anemia9 eas& "r!ising and "leeding assciated #ith

thrm"c&t$enia9 r %e)er and in%ectin secndar& t ne!tr$enia. ;ne $ain and

arthralgias are less


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ALL. Massi)e he$ats$lenmegal& is !ncmmn e4ce$t in in%ants #ith AML +Seiter'

//81.

;ne marr# as$iratin and "i$s& are the de%initi)e diagnstic tests.

A$$r4imatel& 5/6 % $atients #ith ac!te le!*emia d nt ha)e circ!lating "lasts atdiagnsis. One r mre % the %ll#ing la" tests ma& "e !sed t diagnse AML and=r

t determine the s$eci%ic s!"t&$e % AML. Sam$les % "ld' "ne marr#' r CS> are

l*ed at !nder a micrsc$e "& a $athlgist and ma& "e re)ie#ed "& the $atient?s

hematlgist=nclgist. ;ased n the cells? si3e' sha$e' and ther traits' dctrs can

classi%& them int s$eci%ic cell t&$es. A *e& element % this classi%icatin is #hether the

cells l* li*e nrmal cells % circ!lating "ld +mat!re1 r lac* %eat!res % nrmal "ld

cells +immat!re1.

The $ercentage % cells in the "ne marr# r "ld that are "lasts +immat!re1 is

$artic!larl& im$rtant. -a)ing at least /6 "lasts in the marr# r "ld is generall&

re(!ired %r a diagnsis % ac!te m&elid le!*emia. AML can als "e diagnsed i% the

"lasts ha)e a chrmsme change that cc!rs nl& in a s$eci%ic t&$e % AML' e)en

th!gh the "last $ercentage desn?t reach /6. In rder %r a $atient t "e cnsidered

t "e in remissin a%ter treatment' the "last $ercentage m!st "e n higher than :6.

Additinal tests that are !sed t cn%irm the diagnsis % AML are as %ll#s.

C&tchemistr& tests in)l)e e4$sing cells t chemical stains +d&es1 that react #ith nl&

sme t&$es % le!*emia cells. >l# c&tmetr& n the ther hand is a techni(!e #hich is

%ten !sed t l* at the cells %rm "ne marr# and "ld sam$les. It is )er& acc!rate

in determining the e4act t&$e % le!*emia. Related tests' called imm!nhistchemistr&

tests' can "e !sed t detect these s!"stances #hen )ie#ing cells !nder a micrsc$e.

These tests are !sed %r i''uno%(enot%ingIS-1 is a $rced!re similar t c&tgenetic testing. It can %ind mst

chrmsme changes +s!ch as translcatins1 that are )isi"le !nder a micrsc$e in

standard c&tgenetic tests' as #ell as sme changes t small t "e seen #ith !s!al

c&tgenetic testing. @er& sensiti)e DNA tests s!ch as $l&merase chain reactin +7CR1

tests can als %ind translcatins t small t "e seen !nder a micrsc$e' e)en i% )er&

%e# le!*emia cells are $resent in a sam$le. These tests ma& als "e !sed a%ter


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treatment t %ind small n!m"ers % le!*emia cells that ma& nt "e )isi"le !nder a

micrsc$e.

There are als se)eral imaging st!dies that might "e dne in $e$le #ith AML'

"!t the& are dne mre %ten t l* %r in%ectins r ther $r"lems' rather than t l*%r the le!*emia itsel%. ;eca!se le!*emia des nt !s!all& %rm )isi"le t!mrs' imaging

tests are % limited )al!e. In sme cases imaging st!dies ma& "e dne t hel$

determine the e4tent % the disease' i% it is th!ght it ma& ha)e s$read "e&nd the "ne

marr# and "ld. R!tine chest 4


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MDS=M7D "!t #ith d&s$lasia in at least :/6 % cells in r mre lineages12 1 AML and

MDS' thera$& related + Al*&lating agent r radiatinancni anemia' and ne!r%i"rmatsis. Us!all&' these $atients

de)el$ AML d!ring childhd9 rarel&' sme ma& $resent in &!ng ad!lthd. Mres!"tle genetic disrders' incl!ding $l&mr$hisms % en3&mes that meta"li3e

carcingens' als $redis$se $atients t AML. Se)eral st!dies demnstrate a

relatinshi$ "et#een radiatin e4$s!re and le!*emia. Earl& radilgists +$rir t

a$$r$riate shielding1 #ere %!nd t ha)e an increased li*elihd % de)el$ing

le!*emia. 7ersns #h sm*e ha)e a small "!t statisticall& signi%icant +dds rati' 5.:1

increased ris* % de)el$ing AML. In se)eral st!dies' the ris* % AML #as slightl&

increased in $e$le #h sm*ed cm$ared #ith thse #h did nt sm*e. E4$s!re t

"en3ene is assciated #ith a$lastic anemia and $anc&t$enia. These $atients %tende)el$ AML.

Treatment % AML is di)ided int t# stages2 ind!ctin % remissin and $st

remissin cnslidatin r intensi%icatin. Lng


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>r c!rrent trends and iss!es' a n!m"er % ne# dr!gs are c!rrentl& in clinical

trials. The t# mst $rmising areas are %arnes&l trans%erase inhi"itrs and dr!gs that

target FLT-. >arnes&l trans%erase inhi"itrs target ras' a mlec!le that is in)l)ed in the

$ath$h&silg& % )ari!s hematlgic malignancies. T# dr!gs % this t&$e' ti$i%arni"

and lna%arni"' are c!rrentl& !nderging clinical trials. Earl& res!lts ha)e demnstrated

res$nses in 5:


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S(ort.ter' o/0e$ti1es2

5. Recgni3ed the cnditin that are threatening t his health

. A$$reciate all the health teaching and c$erate #ith the n!rsing

inter)entins dne %r his cm%rt

. A$$l& meas!res ta!ght t $re)ent the #rsening % his cnditin

Long.ter' o/0e$ti1es2

5. Maintain a health& li%est&le that is cntri"!tr& t health maintenance and

$ersnal de)el$ment

. In time' s!stain li%est&le that "est ens!re $tim!m le)el % %!nctining

.;raden *n#ledge regarding sel%


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5. Im$r)e= dee$en the n!rses !nderstanding' *n#ledge and s*ills #ith the

disease.

. 7rmte e%%ecti)e n!rsing care t all the clients that ma& "e handled in the

%!t!re #ith the same disease cnditin.

. A$$l&=share the learning %rm the e4$erience t clleag!es' st!dents' clients ,

demnstrate a caring rle as a n!rse has.

0. Identi%& areas related t illness in children that c!ld "ene%it %rm additinal

n!rsing research r a$$licatin % e)idenceili$in citi3en' "a$ti3ed as a Rman Cathlic'

and a resident % 0 ; Ri3al St.' La$a3 Tarlac. -e #as admitted in a tertiar&

g)ernment hs$ital in Tarlac' last Oct"er ' // #ith chie% cm$laints %

e$ista4is' g!m "leeding and l# "ld and $latelet c!nt.

The ;i" %amil& is a n!clear t&$e % %amil& cm$sing % three mem"ers9

his mther' %ather and Tt& ;i" himsel%. -is %ather and mther are "th 5

&ears % age. -is %ather %rmerl& #r*s as a sec!rit& g!ard at a %irm in Manila and

is c!rrentl& sel%


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"!ilding that is in "ad cnditin "eca!se % a %ire incident lng ag. The residents

are als cm$laining % %!l smelling air "eca!se % a $!ltr& lcated in%rnt %

their )icinit&. Their tilet is #ater sealed and the& ha)e #ater $!m$ as the s!rce

% #ater s!$$l&. Accrding t the mther their $lace is small "!t clean and #ell

maintained' #ith a small li)ing rm' ne "edrm #here the %amil& slee$s

tgether' a *itchen and a cm%rt rm. Their #ater is "iled "e%re it is !sed "&

the %amil&. Mrs. ;i" als mentined that the %ather % Tt& ;i" ccasinall&

sm*es and drin*s #ith his $eers. The mther n the ther hand is %nd %

s#eets and %ds rich in car"h&drates' es$eciall& d!ring her $regnanc&. She

als admits that at an earl& age' the& alread& %%ered Tt& ;i" s%tdrin*s r

car"nated drin*s %r re%reshment.

As %r the %amilies health "elie% and $ractices' the %amil& "elie)e in se)eral

s!$erstitins #hich a%%ect their F!dgment and decisins smetimes. The ;i"

%amil& "elie)es in %aith healers and Jmanghihilt es$eciall& #hen smene get

%ract!res r s$rains. The& als ma*e !se % her"al medicines t heal se)eral

cnditins #hich the& cntem$late t "e e%%ecti)e and at the same time

ine4$ensi)e. The& als $ractice sel%


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his mther. -e #as %irst %ed "& %rm!lated mil* *n#n as &ona' then a%ter t#

mnths #as changed t rice mil* r #hat is cmmnl& called as 3a'4 deri)ed

%rm "iled rice. A%ter that Tt& ;i" #as %ed in cm"inatin % &ear &rand# a'

and Mi5o. -e #as than intrd!ced t eating 5uga6' mashed carrt' $tat and

s(!ash. It #as als mentined that e)en "e%re reaching his %irst "irthda&' the

$arents alread& gi)e s%tdrin*s %r Tt& ;i" t drin*. -e is cm$letel&

imm!ni3ed at the lcal health center in La$a3' and #as cmmnl& nted t "e

)er#eight d!ring his mnthl& chec* !$s.

Tt& ;i" "eing three &ears % age is a tddler !nder the A!tnm& @S

shame and D!"t in Eri* Eric*sns 7s&chscial De)el$ment ther&' #here

the child %c!ses n sel%AMILY


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Legend:

Red < -&$ertensin=-eart Disease Yell#T!"erc!lsis

Green Asthma

Figure 1. Genogram

The $aternal grand$arents % Tt& ;i" are *n#n t ha)e h&$ertensins and

all % his !ncle and a!nts incl!ding his %ather ha)e asthma. In his maternal side' Tt&

;i"s grand%ather ha)e alread& $assed a#a& d!e t str*e. -is grandmther n the

ther hand is still li)ing "!t has a histr& % t!"erc!lsis. There are n *n#n disease

r illness that ha)e "e%allen her a!nts and !ncles in his mther side. All are in gd

health as % the $resent.

D. -ISTORY O> 7AST ILLNESS

Tt& ;i" has a histr& % "eing "r!ght at the emergenc& de$artment % a

district hs$ital in La$a3 Tarlac se)eral times at an earl& age % 5


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March ' //' Tt& ;i" #as r!shed t a tertiar& g)ernment hs$ital in

Tarlac Cit& a%ter "eing s!ggested "& the dctrs in the district hs$ital in La$a3 #hen

res!lts % his $latelet and "ld cm$nents #ere %!nd t "e "el# nrmal and in need

% immediate "ld trans%!sin. Se)ere $aleness and a mar*ed decreased %

hemgl"in c!nt % /. 7-YSICAL EAMINATION

Oct"er ' //' Emergenc& Rm 7ediatrics resident


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Genera! "ur#e$

Seen $atient n "ed' #ith I@> % D: /. NaCl at :/ cc le)el in%!sing n his le%t ce$halic

)ein. 7atient is cr&ing and restless9 #ith "d& malaise9 increased res$iratr& e%%rt #ithminimal m)ement9 needs %!ll assistance t d ADL. -e #as #earing a shirt and a $air

% $aFamas. N a$$etite "!t #ith increased #ater inta*e +0


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a. General2 n di%%ic!lt& #ith nec* m"ilit&". ;ld )essels2 slight distensin % F!g!lar )ein is nted.c. Trachea2 n masses nted' and n th&rid gland enlargement.

Integumentar$:a. S*in2 $ale in clr' #ith #arm s*in' $etechial rashes n "th $alm % the

hands' #ith min!te hematma nted n Fint areas n "th !$$er and

l#er e4tremit&'". Nails2 shrt and clean9 #ith ca$illar& re%ill % secnds' a"sence %

cl!""ing and disclratinc. -air2 #ith e(!al distri"!tin % hair

L$m+% NodesBith slightl& enlarged cer)ical l&m$h ndes

%estac*:a. Res$iratin2 #ith nta"le increase in res$iratr& rate' #ith slight

di%%ic!lt& in "reathing". L!ngs2 Rales a!sc!ltated %rm "th l!ng %ields.c. Chest2 #ith e(!al chest e4$ansin' #ith e(!al anteri$sterir

diameter' n a"nrmal retractin' circ!m%erence meas!ring 0 cm in

#idth. @isi"le heart "eat ntedd. ;ac*2 #ith min!te hematma at the "ac* , $rminent at sh!lder

"ladesardio#ascu!ar:

a. -eart2 $siti)e S5 and S s!nds' n m!rm!r". 7eri$heral $!lses2 negati)e $al$itatins #ith nrmal rate

Gastrointestina!:a. A"dmen2 #ith rigid a"dmen9 a"dminal girth % 8 cm9 n striae r

rashes nted' n $rtr!ding mass r discharge n the !m"ilic!s' nascites' nrmacti)e "#el s!nds' n re"!nd tenderness' n

tenderness n *idne&s and li)er !$n $al$atin.uscu!os*e!eta!:

a. U$$er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)identdistensin % )eins' and e(!al $!lses' n edema nted. 7ale #ith$etechial rashes n "th $alms % the hands and min!te hematman Fint areas.

". L#er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)identdistensin % )eins' and e(!al $!lses. Bith enlarged "leedinghematma at the le%t %t meas!ring a"!t 0


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s#all#ing the %d1. Bith increased #ater inta*e +0


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". Nails2 shrt and clean9 #ith ca$illar& re%ill % secnds' a"sence %cl!""ing and disclratin

c. -air2 #ith e(!al distri"!tin % hairL$m+% Nodes

Bith slightl& enlarged cer)ical l&m$h ndes%estac*:

a. Res$iratin2 #ith nta"le increase in res$iratr& rate' #ith slightdi%%ic!lt& in "reathing

". L!ngs2 Rales a!sc!ltated %rm "th l!ng %ields.c. Chest2 #ith e(!al chest e4$ansin' #ith e(!al anteri$sterir

diameter' n a"nrmal retractin' circ!m%erence meas!ring 0 cm in#idth. @isi"le heart "eat nted

d. ;ac*2 #ith min!te hematma at the "ac* , $rminent at sh!lder"lades

ardio#ascu!ar:a. -eart2 $siti)e S5 and S s!nds' n m!rm!r". 7eri$heral $!lses2 negati)e $al$itatins #ith nrmal rate

Gastrointestina!:

a. A"dmen2 #ith rigid a"dmen9 a"dminal girth % 8 cm9 n striae rrashes nted' n $rtr!ding mass r discharge n the !m"ilic!s' nascites' nrmacti)e "#el s!nds' n re"!nd tenderness' ntenderness n *idne&s and li)er !$n $al$atin.

uscu!os*e!eta!:a. U$$er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)ident

distensin % )eins' and e(!al $!lses' n edema nted. 7ale #ith$etechial rashes n "th $alms % the hands and min!te hematman Fint areas.

". L#er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)identdistensin % )eins' and e(!al $!lses. Bith enlarged "leedinghematma at the le%t %t meas!ring a"!t :


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P%$sica! assessment:&ead and Face:

a. -air2 #ith %ine shrt "lac* hair". Scal$2 n e)idence % dandr!%% r %la*ing9 n tenderness % the scal$

nted.c. S*!ll2 nrmal s*!ll cn%ig!ratin' n a"nrmal ele)atin r de$ressin.

d. >ace2 s&mmetrical in sha$e' n tenderness !$n $al$atin and ncre$it!s heard #hile m)ing the Fa#

'$es:a. General2 e&es are s&mmetrical' #ith nted hematma $erir"ital

edema +racn


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a. Res$iratin2 #ith nta"le increase in res$iratr& rate' #ith slightdi%%ic!lt& in "reathing

". L!ngs2 Rales a!sc!ltated %rm "th l!ng %ieldsc. Chest2 #ith e(!al chest e4$ansin' #ith e(!al anteri$sterir

diameter' n a"nrmal retractin' circ!m%erence meas!ring 0 cm in#idth. @isi"le heart "eat nted

d. ;ac*2 #ith min!te hematma at the "ac* , $rminent at sh!lder"lades

ardio#ascu!ar:a. -eart2 $siti)e S5 and S s!nds' n m!rm!r". 7eri$heral $!lses2 negati)e $al$itatins #ith nrmal rate

Gastrointestina!:a. A"dmen2 #ith a"dminal distentin' a"dminal girth % 80 cm9 n

striae r rashes nted' n $rtr!ding mass r discharge n the!m"ilic!s' n ascites' nrmacti)e "#el s!nds' n re"!ndtenderness' n tenderness n *idne&s and li)er !$n $al$atin.

uscu!os*e!eta!:a. U$$er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)ident

distensin % )eins' and e(!al $!lses' n edema nted. 7ale #ith$etechial rashes n "th $alms % the hands and min!te hematman Fint areas.

". L#er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)identdistensin % )eins' and e(!al $!lses. Bith enlarged "leedinghematma at the le%t %t meas!ring a"!t 8 % 7lain NSS 5 liter at // cc

le)el in%!sing n his le%t ce$halic )ein' #ith nging 5 !nit % 7R;C SQ:50 as side dri$'

+1 $allr' restless and irrita"le' "arel& *n# the $e$le handling him incl!ding his

$arents' generali3ed "d& #ea*ness9 #ith e4ertinal "reathing.

P%$sica! assessment:&ead and Face:

a. -air2 #ith %ine shrt "lac* hair". Scal$2 n e)idence % dandr!%% r %la*ing9 n tenderness % the scal$

nted.

c. S*!ll2 nrmal s*!ll cn%ig!ratin' n a"nrmal ele)atin r de$ressin.d. >ace2 s&mmetrical in sha$e' n tenderness !$n $al$atin and n

cre$it!s heard #hile m)ing the Fa#'$es:

a. General2 e&es are s&mmetrical' #ith nted hematma $erir"italedema +racn


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d. E&elids and E&elashes2 n e)idence % in%ectin' n nd!les andtenderness nted' #ith minimal s#elling % l#er e&elid.

e. Lacrimal $!ncta2 n nd!les and tenderness nted.%. Sclerae2 #hitish sclerae #ith e)ident ca$illaries' n Fa!ndice nted.g. CnF!ncti)a2 $ale cnF!ncti)a.h. @isin2 #ith gd )is!al ac!it&

'ars:a. E4ternal2 s&mmetrical a$$earance % $inna' n lesins r a"nrmal

discharges r s#elling.". Internal2 n discharges ntedc. Cranial Ner)e @III2 n hearing im$airment % "th ears

Nose:S&mmetrical nares' n discharge' e4!dates' n "leeding nr s#elling

nted.out% and )%roat:

a. M!th=Li$s2 dr& , crac*ed' #ith dried #!nd n "th li$s' #ith mildsres n ral ca)it&' #ith n "leeding nted.

". Tng!e2 nt assessed

c. S%t $alate and !)!la2 nt assessedd. Thrat2 nt assessed

Nec*:a. General2 n di%%ic!lt& #ith nec* m"ilit&". ;ld )essels2 distended F!g!lar )ein.c. Trachea2 n masses nted' and n th&rid gland enlargement.

Integumentar$:a. S*in2 $ale in clr' #ith #arm s*in' $etechial rashes n "th $alm %

the hands' #ith min!te hematma nted n Fint areas n "th !$$er

and l#er e4tremit&". Nails2 shrt and clean9 #ith ca$illar& re%ill % :


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a. U$$er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)identdistensin % )eins' and e(!al $!lses' n edema nted. 7ale #ith$etechial rashes n "th $alms % the hands and min!te hematman Fint areas.

". L#er E4tremities2 e(!al in si3e' s&mmetrical in sha$e #ith n e)identdistensin % )eins' and e(!al $!lses. Bith enlarged "leeding

hematma at the le%t %t meas!ring a"!t 8


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Medical $rced!res ha)e "een de)el$ed t e4amine the "ne marr# +"ne marr#

as$iratin and "i$s&1 % $atients and als t trans%er nrmal stem cells %rm a dnr

int a reci$ient +"ne marr# trans$lantatin1.

STRUCTURE

Red marr# cnsists $rimaril& % a lse' s%t net#r* % "ld )essels and $rtein

%i"ers inters$ersed #ith de)el$ing "ld cells. The "ld )essels are termed the

)asc!lar cm$nent' and the $rtein %i"ers and de)el$ing "ld cells cllecti)el& are

re%erred t as the strma' r the e4tra)asc!lar cm$nent. The $rtein %i"ers crisscrss

the marr#' %rming a mesh#r* that s!$$rts the de)el$ing "ld cells cl!stered in

the s$aces "et#een the %i"ers.

Red marr# cntains a rich "ld s!$$l&. Arteries trans$rt "ld cntaining 4&gen

and n!trients int the marr#' and )eins rem)e "ld cntaining car"n di4ide and

ther #astes. The arteries and )eins are cnnected "& ca$illaries' "ld )essels that

"ranch thr!gh!t the marr#. In )ari!s $laces' the ca$illaries "alln !t' %rming

n!mer!s thin' "ld


22/44

Gra$s natom$ i!!ustration o3 ce!!s in bone marro. (From Ne 4or!d'nc$c!o+edia

>UNCTIONS

Red marr# $rd!ces all % the "d&s "ld cellsred "ld cells' #hite "ld cells'

and $latelets. Red "ld cells in the circ!latr& s&stemtrans$rt 4&gen t "d& tiss!es

and car"n di4ide a#a& %rm tiss!es. Bhite "ld cells are critical %r %ighting "acteria

and ther %reign in)aders % the "d&. 7latelets are essential %r the %rmatin % "ld

clts t heal #!nds.

Bithin red "ne marr#' all "ld cells riginate %rm a single t&$e % cell' called a

hemat$ietic stem cell. Stim!lated "& hrmnes and gr#th %actrs' these stem cells

di)ide t $rd!ce immat!re' r $rgenitr "ld cells. Mst % these $rgenitr cells

remain in the strma and ra$idl& !nderg a series % cell di)isins' $rd!cing either red

"ld cells r #hite "ld cells. At an& ne time' the strma cnsists largel& %

$rgenitr cells in )ari!s stages % de)el$ment. At the a$$r$riate de)el$mental

stage' the %resh' ne# cells s(!ee3e thr!gh the #alls % the ca$illaries. >rm there' the

cells lea)e the "ne and enter the "d&s circ!latr& s&stem. Sme $rgenitr cells
http://encarta.msn.com/encyclopedia_761566878/Circulatory_System.htmlhttp://encarta.msn.com/encyclopedia_761566878/Circulatory_System.html


23/44

migrate t the sin!sids' #here the& $rd!ce $latelets' #hich als tra)el t the

circ!latr& s&stem )ia the ca$illaries.

Alth!gh stem cells are relati)el& rarea"!t 5 in e)er& 5/'/// marr# cells is a stem

cellthe& t&$icall& $rd!ce the %rer!nners % an estimated millin red cells $ersecnd and "illin $latelets $er da&. -#e)er' i% signi%icant am!nts % "ld are lst

r ther cnditins red!ce the s!$$l& % 4&gen t tiss!es' the *idne&s secrete the

hrmne er&thr$ietin. This hrmne stim!lates stem cells t $rd!ce mre red "ld

cells. T %ight %% in%ectin' hrmnes cllecti)el& termed $o5on sti'u5ating gro6t(

fa$tors are released "& the imm!ne s&stem. These hrmnes stim!late the stem cells t

$rd!ce mre in%ectin


24/44

Note t(at so'e $o'%5e7it is o'itted fro' t(e diagra'" L'%(o$tes $o'e fro'

8L'%(oid8 5ine# 6(ereas granu5o$tes# 'ono$tes# 'ega9aro$tes# and ert(ro$tes

$o'e fro' 8Me5oid8 5ine" A'ong 'e5oid $e55s# granu5o$tes and 'ono$tes(a1e a

$o''on %re$ursor# 8CFU.GM8"

-emat$iesis cc!rs in the "ne marr#. The degree and lcatin % "ne

marr# acti)it& )aries de$ending n the age and health stat!s % &!r $atient. Bithin the

"ne marr# there is a $l!ri$tent stem cell. This stem cell is the JMther Cell r the

riginatr % all "ld cells. It has the a"ilit& t sel%


25/44

;ld is a li(!id tiss!e. S!s$ended in the #ater& $lasma are se)en t&$es % cells

and cell %ragments. The Red ;ld Cells +R;Cs1 r er&thrc&tes ' 7latelets r

thrm"c&tes' and %i)e *inds % #hite "ld cells +B;Cs1 r le!*c&tes. Three *inds %

gran!lc&tes are as %ll#s2 Ne!tr$hils' Esin$hils' ;as$hils. T# *inds %

le!*c&tes #ith!t gran!les in their c&t$lasm are2 L&m$hc&tes and Mnc&tes'

Functions o3 t%e !ood

;ld $er%rms t# maFr %!nctins2 trans$rt thr!gh the "d& % 2 4&gen and

car"n di4ide' %d mlec!les +gl!cse' li$ids' amin acids1' ins +e.g.' Na' Ca'

-CO1' #astes +e.g.' !rea1' hrmnes' heat and de%ense % the "d& against in%ectins

and ther %reign materials. All the B;Cs $artici$ate in these de%enses.

Red Blood Cells (erythrocytes)

The mst n!mer!s t&$e in the "ld. Bmen a)erage a"!t 0. millin % these

cells $er c!"ic millimeter +mm9 #hich is the same as a micrliter VlW1 % "ld. Men

a)erage a"!t :.0 4 5/8$er Vl. These )al!es can )ar& )er (!ite a range de$ending n

s!ch %actrs as health and altit!de. +7er!)ians li)ing at 5'/// %eet ma& ha)e as man&

as . 4 5/8R;Cs $er Vl.1 R;C $rec!rsrs mat!re in the "ne marr# clsel& attached

t a macr$hage. The& man!%act!re hemgl"in !ntil it acc!nts %r sme /6 % the

dr& #eight % the cell. The n!cle!s is s(!ee3ed !t % the cell and is ingested "& the

macr$hage. N


26/44

Mst % the irn in their hemgl"in is reclaimed %r re!se. The remainder % the heme

$rtin % the mlec!le is degraded int "ile $igments and e4creted "& the li)er. Sme

millin R;Cs die and are sca)enged "& the li)er each secnd. Red "ld cells are

res$nsi"le %r the trans$rt % 4&gen and car"n di4ide.

Hemoglobin

-emgl"in is a $rtein that is carried "& red cells. It $ic*s !$ 4&gen in the l!ngs

and deli)ers it t the $eri$heral tiss!es t maintain the )ia"ilit& % cells. -emgl"in is

made %rm t# similar $rteins that stic* tgether. ;th $rteins m!st "e $resent %r

the hemgl"in t $ic* !$ and release 4&gen nrmall&. One % the cm$nent $rteins

is called al$ha' the ther is "eta. ;e%re "irth' the "eta $rtein is nt e4$ressed. A

hemgl"in $rtein %!nd nl& d!ring %etal de)el$ment' called gamma' s!"stit!tes !$

!ntil "irth.

In ad!lt h!mans the hemgl"in +-"1 mlec!le cnsists % %!r $l&$e$tides2 t#

al$ha +X1 chains % 505 amin acids and t# "eta +1 chains % 508 amin acid. Each %

these is attached the $rsthetic gr!$ heme. There is ne atm % irn at the center %

each heme. One mlec!le % 4&gen can "ind t each heme.

Li*e all $rteins' the "l!e$rint %r hemgl"in e4ists in DNA +the material that

ma*es !$ genes1. Nrmall&' an indi)id!al has %!r genes that cde %r the al$ha $rtein'

r al$ha chain. T# ther genes cde %r the "eta chain. +T# additinal genes cde %r

the gamma chain in the %et!s1. The al$ha chain and the "eta chain are made in $recisel&

e(!al am!nts' des$ite the di%%ering n!m"er % genes. The $rtein chains Fin in

de)el$ing red "ld cells' and remain tgether %r the li%e % the red cell.

-emgl"in s&nthesis re(!ires the crdinated $rd!ctin % heme and gl"in.

-eme is the $rsthetic gr!$ that mediates re)ersi"le "inding % 4&gen "& hemgl"in.

Gl"in is the $rtein that s!rr!nds and $rtects the heme mlec!le.

'r$t%roc$tes and 6e!ated 7a!ues

6ed !ood e!! (6

Norma! 6ange: .9-9. ;109mm (ma!es

.2 -/. ;109mm (3ema!es


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Er&thrc&tes' r red "ld cells' riginate %rm a stem cell. @itamin ;5' %lic acid' irn'

and c$$er are essential in the %rmatin % er&thrc&tes. Er&thr$ietin is released "&

*idne&s in res$nse t h&$4emia #hich stim!lates the "ne marr# t $rd!ce red

"ld cells. T&$icall&' red "ld cells li)e a$$r4imatel& 5/ da&s. Bhen the red "ld

cells "ecme ld and damaged' the li)er' s$leen' and "ne marr# cleanse them %rm

the "ld.

6eticu!oc$te ount

Norma! 6ange: 0./-2./< o3 6s

Bhen released %rm the "ne marr# red "ld cells are slightl& immat!re and are

*n#n as retic!lc&tes. Retic!lc&tes mat!re int red "ld cells #ithin a %e# da&s.

&emog!obin

Norma! 6ange: 1-18 gdL (ma!es

12-19 gd! (3ema!es

-emgl"in is a $rteinr e4am$le2

I% &!r $atients hemgl"in is ./ g=dl' and &! gi)e him ne !nit % $ac*ed red "ld

cells' &!r $atients hemgl"in sh!ld cme !$ t ./ g=dl.

&ematocrit

Norma! 6ange: 2-/2< (ma!es

=-/=< (3ema!es

-ematcrit is an e4$ressin % the ttal $ercentage % "ld )l!me that is cm$sed %

red "ld cells. It is als *n#n as the $ac*ed cell )l!me % &!r "ld +Sher#d'

51.

Iron

Norma! 6ange: /0-1/0 mcgdL

As mentined earlier' irn is necessar& %r the %rmatin % hemgl"in' an essential $art

% the red "ld cell. Irn is a"sr"ed %rm the small intestine int the "ld and "inds


28/44

#ith trans%errin. Trans%errin trans$rts irn tthe "ne marr# #here it is !sed t ma*e

hemgl"in.

)ota! Iron inding a+acit$

Norma! 6ange: 2/0-10 mcgd!

The am!nt % irn that can still "ind #ith trans%errin +t "e trans$rted t "ne marr#

t ma*e hemgl"in1 is *n#n as the ttal irn "inding ca$acit& r TI;C. Thin* % &!r

TI;C as the ttal am!nt % $e$le that can get n a "!s. The irn is the $e$le and the

"!s is trans%errin. Bhen &!r ser!m irn le)els increase' &!r TI;C decreases. Bhen

&! ser!m irn le)els decrease' then &!r TI;C increases.

Ferritin

Norma! 6ange: 20 - 00 ngmL (ma!es

20 - 120 ngmL (3ema!es

>erritin is a $rtein that "inds t irn. Mst % the irn stred in the "d& is attached t

%erritin. >erritin is %!nd in the li)er' s$leen' and "ne marr#. Onl& a small am!nt is

%!nd in the "ld. Li*e the TI;C' the am!nt % %erritin in the "ld ma& hel$ indicate

the am!nt % irn stred in &!r "d&.

4%ite !ood e!! ount (4 and >i33erentia!

Bhite "ld cells' r le!*c&tes' are classi%ied int t# main gr!$s2

gran!lc&tes and nngran!lc&tes +als *n#n as agran!lc&tes1. The gran!lc&tes'

#hich incl!de ne!tr$hils' esin$hils' and "as$hils' ha)e gran!les in their cell

c&t$lasm. Ne!tr$hils' esin$hils' and "as$hils als ha)e a m!ltil"ed n!cle!s. As a

res!lt the& are als called $l&mr$hn!clear le!*c&tes r $l&s. The n!clei %ne!tr$hils als a$$ear t "e segmented' s the& ma& als "e called segmented

ne!tr$hils r segs. The nngran!lct&e #hite "ld cells' l&m$hc&tes and

mnc&tes' d nt ha)e gran!les and ha)e nnl"!lar n!clei. The& are smetimes

re%erred t as mnn!clear le!*c&tes.
http://www.rnceus.com/cbc/cbcdiff.htmlhttp://www.rnceus.com/cbc/cbcdiff.html


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The li%es$an % #hite "ld cells ranges %rm 5 t / da&s' a%ter #hich time the&

are destr&ed in the l&m$hatic s&stem. Bhen immat!re B;Cs are %irst released %rm the

"ne marr# int the $eri$heral "ld' the& are called "ands r sta"s. Le!*c&tes

%ight in%ectin thr!gh a $rcess *n#n as $hagc&tsis. D!ring $hagc&tsis' the

le!*c&tes s!rr!nd and destr& %reign rganisms. Bhite "ld cells als $rd!ce'

trans$rt' and distri"!te anti"dies as $art % the "d&?s imm!ne res$nse.

Leu*oc$tes

)ota! 4

Norma! 6ange: /,000 -10,000micro!iter

Le!*c&tes' r #hite "ld cells' $rtect the "d& %rm "acteria and in%ectin.

The #hite "ld cell c!nt is e4$ressedas the n!m"er % le!*c&tes $er micrliter %

"ld. The ttal B;C c!nt increases in res$nse t in%ectin r tra!ma.

L$m+%oc$tes

Norma! 6ange: 19-9inall&' the

clt m!st "e dissl)ed in rder %r nrmal "ld %l# t res!me %ll#ing tiss!e re$air.

The dissl!tin % the clt cc!rs thr!gh the actin % $lasmin. 7lasmin is a $rtein that

is res$nsi"le %r digesting %i"rin. E)ent!all&' scar tiss!e %rms cm$leting the healing %

the inF!red )essel +Sher#d' 51.

P!asma

7lasma is a stra#


34/44

I@. T-E 7ATIENT AND -IS ILLNESS

A.7AT-O7-YSIOLOGY +;OOK CENTERED1

7redis$sing >actrs2Race + Bhite race 1Gender +Male1

Age +increases #ith age1-eredit&=>amilial Tendenc&

7reci$itating >actrs2Antecedent -ematlgicDisrdersCngenital DisrderEn)irnmental E4$s!res +high dses% radiatin' chemicals li*e "en3ene't"acc Sm*e17rir E4$s!re T Chemthera$e!tic

Agents >r Anther Malignanc&


35/44

A%%ectatins in di%%erent cmmitted cells

M!tant le!*emia cells $rli%erate and %ill the"ne marr#

Cm$ete and in%iltrate hemat$eisis ,s$reads "e&nd the marr# and tiss!e

rgans

Er&thr"lasts

7rli%eratin %

immat!re$hagc&tes

Decreased

$rd!ctin %nrmal R;C

Decreased

4&gencarr&ing

ca$acit& % the"ld

Mega*ar&idCmmitted Cells

Mega*ar&"last

7rli%eratin %immat!re

mega*ar&c&tes

Immat!re$latelet

$rd!ctin

M&elid Cmmitted CellsM&el"lasts

7rli%eratin %

immat!rem&elc&tes

Increased

immat!re B;C$rd!ctin

L&m$h"las

7rli%eratin immat!re

l&m$hc&te

A%%ectatins ; l&m$hc&t

, T T-E DISEASE

G'N'6L >'"6IP)ION

The !nderl&ing $ath$h&silg& cnsists % a mat!ratinal arrest % "ne marr#

cells in the earliest stages % de)el$ment. The mechanism % this arrest is !nder st!d&'

"!t in man& cases' it in)l)es the acti)atin % a"nrmal genes thr!gh chrmsmal

translcatins and ther genetic a"nrmalities. This de)el$mental arrest res!lts in

disease $rcesses. >irst' the $rd!ctin % nrmal "ld cells mar*edl& decreases'

#hich res!lts in )ar&ing degrees % anemia' thrm"c&t$enia' and ne!tr$enia.

7etechiaeEcch&msis

Gingi)al"leedinge$ista4is

;leedingTendencies

$allrAnemia

Bt. lss Malaise

Eas& %atiga"ilit&

Ris* %r in%ectin

A%%ectatinsin B;C cellscm$nents

Ne!tr$hils;as$hils

Esin$hils

Ina"ilit& t $rtect"d& against

in)asin


37/44

Secnd' the ra$id $rli%eratin % these cells' alng #ith a red!ctin in their a"ilit& t

!nderg $rgrammed cell death +a$$tsis1' res!lts in their acc!m!latin in the "ne

marr#' "ld' and' %re(!entl&' the s$leen and li)er.

". RISK >ACTORS

P6'->I"PO"ING F)O6"2

6' < AML is mre cmmn in #hites than in ther $$!latins.

"'; < AML is mre cmmn in men than in #men. The di%%erence is e)en mre

a$$arent in lder $atients. Sme ha)e $r$sed that the increased $re)alence %

AML in men ma& "e related t cc!$atinal e4$s!res.

G' < 7re)alence increases #ith age. The median age % nset is 8: &ears. -#e)er'this disease a%%ects all age gr!$s.

>AMILIAL TENDENCY < Germ


38/44

thera$e!tic irradiatin %r an*&lsing s$nd&litis #ere at increased ris* % le!*emia.

S!r)i)rs % the atmic "m" e4$lsins in Ha$an #ere at a mar*edl& increased ris* %r

the de)el$ment % le!*emia. 7ersns #h sm*e ha)e a small "!t statisticall&

signi%icant +dds rati' 5.:1 increased ris* % de)el$ing AML. In se)eral st!dies' the ris*

% AML #as slightl& increased in $e$le #h sm*ed cm$ared #ith thse #h did nt

sm*e. E4$s!re t "en3ene is assciated #ith a$lastic anemia and $anc&t$enia.

These $atients %ten de)el$ AML. Man& % these $atients demnstrate M8 mr$hlg&.

7RIOR E7OSURE TO C-EMOT-ERA7EUTIC AGENTS >OR ANOT-ER

MALIGNANCY < As mre $atients #ith cancer s!r)i)e their $rimar& malignanc& and

mre $atients recei)e intensi)e chemthera$& +incl!ding "ne marr# trans$lantatin

;MTW1' the n!m"er % $atients #ith AML increases "eca!se % e4$s!re t

chemthera$e!tic agents. 7atients #ith a $rir e4$s!re t al*&lating agents' #ith r#ith!t radiatin' %ten ha)e a m&eld&s$lastic $hase $rir t the de)el$ment % AML.

The t&$ical latenc& $erid "et#een dr!g e4$s!re and ac!te le!*emia is a$$r4imatel&


39/44

.Fe#er and ot%er signs o3 in3ectioncan cc!r' incl!ding l!ng %indings % $ne!mnia

These are d!e t the lac* % nrmal #hite "ld cell $rd!ctin that ma*es the $atient

s!sce$ti"le t in%ectins' #hile the le!*emic cells are deri)ed %rm #hite "ld cell

$rec!rsrs' the& ha)e n in%ectin


40/44

. P)&OP&5"IOLOG5 (LI'N)-'N)'6'>

7redis$sing >actrs2

Gender +Male1Age + &ears ld1

7reci$itating >actrs2

En)irnmental E4$s!res< Cigarette Sm*e< E4$s!re t certain chemicals+car"nated drin*s e)en "e%rereaching 5


41/44


M!tant le!*emia cells $rli%erate and %ill the"ne marr#

Cm$ete and in%iltrate hemat$eisis ,s$reads "e&nd the marr# and tiss!e

rgans

Er&thr"lasts

7rli%eratin %

immat!re$hagc&tes

Decreased

$rd!ctin %nrmal R;C

Decreased

4&gencarr&ing

ca$acit& % the"ld+-g"1

Mega*ar&idCmmitted Cells

Mega*ar&"last


mega*ar&c&tes

Immat!re$latelet

$rd!ctin

M&elid Cmmitted CellsM&el"lasts

7rli%eratin %

immat!rem&elc&tes

Increased

immat!re B;C$rd!ctin

Er&thrid CmmittedCells

Disr!$tin % $l!ri$tent stem cells

Disr!$tin % s$eci%ic genes


Mn"lasts


mnc&tes

Decreased$hagc&tic acti)it&

% mnc&tes


42/44

a. SYNT-ESIS O> T-E DISEASE +CLIENT ;ASED1

GENERAL DESCRI7TION

The !nderl&ing $ath$h&silg& cnsists % a mat!ratinal arrest % "ne marr#

cells in the earliest stages % de)el$ment. This de)el$mental arrest res!lts in

disease $rcesses. >irst' the $rd!ctin % nrmal "ld cells mar*edl& decreases'

#hich res!lts in )ar&ing degrees % anemia' thrm"c&t$enia' and ne!tr$enia.

Secnd' the ra$id $rli%eratin % these cells' alng #ith a red!ctin in their a"ilit& t

] 7etechiae^+"th $alms % the hand1

] Ecch&msis^

] Gingi)al "leeding^

] E$ista4is +!$nadmissin1

] -ematma^


43/44

!nderg $rgrammed cell death +a$$tsis1' res!lts in their acc!m!latin in the "ne

marr#' "ld' and' %re(!entl&' the s$leen and li)er. In AML' the "ne

". RISK >ACTORS

P6'->I"PO"ING F)O6"2

"'; < AML is mre cmmn in men than in #men. The di%%erence is e)en mre

a$$arent in lder $atients.

G'< 7re)alence increases #ith age. The median age % nset is 8: &ears. -#e)er'

this disease a%%ects all age gr!$s.

P6'IPI))ING F)O6"2

EN@IRONMENTAL E7OSURES < In se)eral st!dies' the ris* % AML #as slightl&

increased in $e$le #h sm*ed cm$ared #ith thse #h did nt sm*e.

C. SIGNS AND SYM7TOMS BIT- RATIONALE

5. nemia, Neutro+enia, and )%romboc$to+enia These are d!e t "ne marr#

%ail!re. It res!lts %rm the %act that as le!*emic clne % cells gr#s' it tends t dis$lace

de)el$ment % nrmal "ld cells in the "ne marr#. There is als decreased

ne!tr$hil le)els des$ite an increased ttal B;C c!nt.

.P%$sica! signs o3 anemia- incl!ding $allr and d&s$nea !$n e4ertin.These are

d!e t the increased n!m"er % #hite "ld cells dis$lacing r ther#ise inter%ering #ith

the $rd!ctin % nrmal "ld cells in the "ne marr#. The mst cmmn s&m$tm %

anemia is %atig!e.

. Fe#er and ot%er signs o3 in3ection7atients $resent #ith %e)er' #hich ma& cc!r

#ith r #ith!t s$eci%ic dc!mentatin % an in%ectin. These are d!e t the lac* %

nrmal #hite "ld cell $rd!ctin that ma*es the $atient s!sce$ti"le t in%ectins' #hile

the le!*emic cells are deri)ed %rm #hite "ld cell $rec!rsrs' the& ha)e n in%ectin

aml case study

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