Thomas 5 year old boy, Northam
PmHx:
- Uncomplicated birth
- reached all developmental milestones at usual ages
- uncomplicated untreated otitis media 9mo ago
Meds/allergies: none noted;
FHx
- Rural background
- recent financial issues
- Mother, Yvonne D. (PT cleaner at school) brought him in
- Father recently started work as aerial spraying contractor after 3mo UE
No family history of bleeding disorders
SHx
- 1st year of school
- progressing well
- happy & alert demeanor
- plays outdoors with friends
Pc
- Several unexplained nose bleeds
- unexplained bleeding from gums
- several bruises to chest & upper arms
Examination:
No signs of trauma/obstruction/infection
Slight pallor, but nails pink
HxPx: Mother suspected abuse by teacher or bully but gums now bleeding
Recent onset bruising
Tender gums; Examination triggers further bleeding
Leg and facial bruising
Signs of recent nosebleeds
Normal chest auscultation; no palpable spleen, liver nor lymph nodes, and normal abdomen palpation
No admission of family/marital discord/abuse
Denies being in contact with father's pesticides
Blood test results
Blood film shows:
- normal erythrocytes
- normal neutrophil
- normal lymphocyte but 2 lymphoblasts present
Blood count:
- mild normochromic anaemia - mildly elevated total white cells
- severely reduced platelet count (50,000/mL)
Bone marrow aspiration & CSF examination: acute lympblastic leukemia w/o cerebral involvement
Treatment: Course of chemotherapy over 3 month period at PCH (treatment with methorexate, cyclophoshamide & doxyrubicin) & LT drug therapy over 2 years
Mother has concerns about the impact of doing chemotherapy in Perth on Thomas & rest of family - looking into other options
Treatment progress/effects: suffers nausea, mouth ulceration, vomiting & diarrhoea after 1st treatment
Visible lymphoblasts indicate issue - usual location in bone marrow
Clotting issues with less platelets (hence bleeding)
Doctor to monitor for febrile neutropenia
High turnover of epithelial cells in GI tract -> distension of lumen with fluid (poor absorption) -> nausea