Leukemia Case Study (60 min)
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Mr. Devito is a 48-year-old male who presents to his Primary Care Provider with left upper abdominal pain and complaints of weakness and fatigue. The nurse immediately notes how pale his skin is. A full set of vital signs reveals the following:
BP 142/90 mmHg
SpO 2 94% on Room Air
What furtner nursing assessments would you perform at this time?
- Heart and lung sounds
- Assess abdomen and review details of abdominal pain (OLDCARTS)
- Assess skin condition (color, quality, turgor, etc.)
- Peripheral perfusion (pulses, cap refill, etc.)
Upon further assessment, the nurse notes a palpable mass in the left upper quadrant, possibly an enlarged spleen, that is tender on palpation. The nurse also notes petechiae and bruising to the patient’s arms and legs. When questioned, the patient says “I seem to bruise so easily these days”. The patient’s lungs have diffuse crackles, heart sounds S1 and S2 present with no murmurs. The patient also reports a slight headache.
What laboratory or diagnostic tests do you anticipate the provider ordering?
- Complete Blood Count (to check for wbc – infection and reason for bruising)
- Full chemistry to ensure no electrolyte abnormalities or renal involvement
- Coagulation studies to determine cause of easy bruising
- Chest X-ray and sputum culture to identify source of infection
The provider orders a complete blood count, chemistry panel, and chest x-ray. The chest x-ray shows the patient has a slight pneumonia. He is sent home with a course of antibiotics while awaiting the test results.
The next day, the lab results show the following:
RBC 4.2 BUN 22
Hgb 8.4 Cr 0.9
Hct 25.2 K 3.9
WBC 144,000 Na 148
Plt 40,000 Ca 7.6
Based on the above lab results, what should the nurse be most concerned about?
- The patient has EXCESSIVE amounts of white blood cells. It would be expected for them to be slightly elevated because of the infection, but this is WAY beyond that.
- The patient is also anemic, with low platelets – this could explain the easy bruising
What do you believe may be going on, physiologically, with Mr. Devito?
- The excessive amounts of White Blood Cells, plus the easy bruising, anemia, and enlarged spleen point to some type of Leukemia.
- The body is excessively making immature, non-functioning white blood cells – hence the patient being susceptible to a pneumonia.
What further diagnostic testing should be performed to confirm a diagnosis?
- A bone marrow biopsy must be done to confirm a leukemia diagnosis
- The provider calls Mr. Devito and explains the results. They set an appointment for Mr. Devito to have a bone marrow biopsy. Biopsy results confirm Mr. Devito has Acute Myeloid Leukemia. Mr. Devito’s wife says “I don’t understand, I thought you said he just had pneumonia?”
How would you explain this to the patient’s wife?
- Leukemia causes the body to make a bunch of immature, non-functioning white blood cells. So when a patient gets an infection, like a respiratory infection, the body’s white blood cells can’t actually fight it off. So it’s common for patients to be prone to infections like pneumonia.
- Mr. Devito DID have pneumonia – but it was due to the poor immune response caused by the Leukemia.
Mr. Devito will be started on high-dose chemotherapy.
What education topics should be included in teaching for Mr. Devito and his wife?
- Mr. Devito will have a special port implanted in order to receive his chemotherapy
- Mr. Devito will likely also receive medications to manage the symptoms of the chemotherapy
- Mr. Devito may lose his hair, depending on the type of chemotherapy used, because chemo also kills healthy fast-growing cells
- Mr. Devito May experience something called neutropenia. This means he will be highly susceptible to infections. He should avoid having lots of visitors, avoid fresh flowers, and especially avoid being around anybody who is sick. He can even wear a mask in public if he so desires.
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Nursing Case Studies
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Nursing Case Studies Introduction
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Acute Lymphocytic Leukemia Case Study
Leukemia is a cancer of white blood cells. In acute leukemia, the abnormal cells divide rapidly, quickly overtaking functional white and red blood cells. The most common form of cancer in children 0-14 years of age is acute lymphocytic leukemia (ALL). The survival rate in children has improved more than 50% in the last half century. Currently, there is a 65.3% overall survival rate; in children under 5 the survival rate increases to 90.4%. Come experience the cancer journey with 6-year-old Noah.
Module 6: Acute Lymphocytic Leukemia
Noah, 6 years old, was brought back to his pediatrician three weeks following a streptococcal throat infection...
Leukemia - Page 1
Upon receiving the results, the physician informed the stunned mother that her child had...
Leukemia - Page 2
A spinal tap was ordered to see if the leukemic cells had crossed the blood/brain barrier...
Leukemia - Page 3
A sputum culture was obtained and sent to the lab for gram stain, culture, and sensitivities...
Leukemia - Page 4
Noah was now in remission. Two weeks after achieving...
Leukemia - Page 5
Summary of the Case
Leukemia - Summary
Answers to Case Questions
Leukemia - Answers
Health Professionals Introduced in Case
Leukemia - Professionals
Optional Links to Explore Further
Leukemia - Links
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Case Study: 47-Year-Old Woman With New-Onset AML and Leukostasis
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A 47-year-old woman presents to the emergency department complaining of fatigue and shortness of breath. She reports a two-week history of worsening exercise tolerance and a rather abrupt onset of shortness of breath over the past several hours. The patient has no major past medical history and works as an architect. Prior to this illness, she exercised three to four times weekly. Her breathing appears somewhat labored. Physical examination is notable for tachycardia, tachypnea, an erythematous rash on her chest and back, and scattered ecchymosis on the extremities. Her laboratory results reveal the following:
White blood cell (WBC) differential is notable for 89 percent blasts. Peripheral blood smear shows a vast majority of cells are large blasts with occasional cytoplasmic granules and pseudopodia. Bone marrow aspiration and biopsy is performed, revealing a hypercellular marrow involved with monocytic-appearing blasts comprising 80 percent of bone marrow cellularity. Cytogenetics reveal t(6;11)(q27;q23) present in 19 out of 20 metaphase cells. Molecular studies show wild-type CEPBA and NPM1 genes and a FLT3-ITD mutation (FMS-like tyrosine kinase 3, internal tandem duplication) is present. She is admitted to the hospital to initiate induction chemotherapy for acute myeloid leukemia (AML).
Following acute cytoreductive strategies to treat pulmonary complications of leukostasis, which of the following FDA-approved induction regimens is most likely to result in long-term overall survival?
- 7+3 chemotherapy with infusional cytarabine and an anthracycline (daunorubicin or idarubicin) plus gemtuzumab ozogamicin
- 7+3 chemotherapy with infusional cytarabine and an anthracycline (daunorubicin or idarubicin), plus etoposide
- 7+3 chemotherapy with infusional cytarabine and an anthracycline (daunorubicin or idarubicin), plus midostaurin
- 7+3 chemotherapy with infusional cytarabine and an anthracycline (daunorubicin or idarubicin), plus sorafenib
The correct answer is (C), 7+3 chemotherapy with infusional cytarabine and an anthracycline (daunorubicin or idarubicin), plus midostaurin. The patient is a younger adult woman with no prior medical history who presents with de novo AML with t(6;11) as well as a FLT3 -ITD mutation. Her clinical presentation is explained by her anemia (fatigue), thrombocytopenia (ecchymoses), and extreme leukocytosis (pulmonary leukostasis). Her cytogenetics reveal an 11q23 translocation, associated with therapy-related AML secondary to topoisomerase II inhibitors (such as etoposide and anthracyclines), which she does not have given her lack of prior history of such exposures, and monocytic differentiation of the leukemia, which she does have on the basis of her morphology. Monocytic differentiation may increase the chance of leukemic blasts infiltrating into tissues, which may result in leukemia cutis (likely based on her exam), gingival hyperplasia, and a higher likelihood of central nervous system involvement. Her very high WBC count is likely a result of her FLT3 -ITD mutation, which is associated with extreme elevations in the WBC count at presentation, a shorter WBC doubling time, and an increased likelihood of relapse following consolidation therapy. Midostaurin is a newly developed inhibitor of FLT3 that is FDA-approved, along with standard 7+3 combination chemotherapy, for the induction therapy of FLT3 mutation-positive AML. This is based on a multicenter phase III trial of 717 adult patients with newly-diagnosed FLT3 mutation-positive AML who were randomized to either standard 7+3 induction chemotherapy plus placebo or 7+3 induction chemotherapy plus midostaurin (on days 8 through 21, following chemotherapy). After a median of 59 months of follow-up, median overall survival was superior in the midostaurin group (75 months vs. 26 months), with a hazard ratio for death of 0.78.
While induction therapy with midostaurin has not been directly compared to such therapy with gemtuzumab ozogamicin (answer choice A), etoposide (answer choice B), or sorafenib (answer choice D), studies have examined the impact of adding etoposide to 7+3 and no benefit over 7+3 alone has been found. Sorafenib is a multi-tyrosine kinase inhibitor with activity against FLT3, and small studies have suggested a possible role for this drug in the management of patients with FLT3 mutation-positive AML, but more investigation is necessary, and the agent is not currently FDA-approved for this purpose. Gemtuzumab ozogamicin is a recombinant anti-CD33 monoclonal antibody linked to a cytotoxic agent. It had initially been approved by the FDA for use in older adults (age >60) with AML in first relapse, but it has since been pulled from the U.S. market following a more recent randomized trial showing no benefit from adding gemtuzumab ozogamicin to standard induction in younger adults with newly diagnosed AML. Trials are ongoing investigating other possible uses of this agent.
Case study submitted by Hanny Al-Samkari, MD, of Massachusetts General Hospital, Dana-Farber Cancer Institute, Harvard University, Boston, MA
- Stone RM, Mandrekar SJ, Sanford BL, et al. Midostaurin plus Chemotherapy for Acute Myeloid Leukemia with a FLT3 Mutation . N Engl J Med. 2017; doi:10.1056/NEJMoa1614359. [Epub ahead of print].
- Bishop JF, Lowenthal RM, Joshua D, et al. Etoposide in acute nonlymphocytic leukemia. Australian Leukemia Study Group . Blood. 1990; 75:27-32.
- Röllig C, Serve H, Hüttmann A, et al. Addition of sorafenib versus placebo to standard therapy in patients aged 60 years or younger with newly diagnosed acute myeloid leukaemia (SORAML): a multicentre, phase 2, randomised controlled trial . Lancet Oncol. 2015; 16:1691-1699.
- Petersdorf SH, Kopecky KJ, Slovak M, et al. A phase 3 study of gemtuzumab ozogamicin during induction and postconsolidation therapy in younger patients with acute myeloid leukemia . Blood. 2013; 121:4854-4860.
American Society of Hematology. (1). Case Study: 47-Year-Old Woman With New-Onset AML and Leukostasis. Retrieved from https://www.hematology.org/education/trainees/fellows/case-studies/female-with-new-onset-aml-and-leukostasis .
American Society of Hematology. "Case Study: 47-Year-Old Woman With New-Onset AML and Leukostasis." Hematology.org. https://www.hematology.org/education/trainees/fellows/case-studies/female-with-new-onset-aml-and-leukostasis (label-accessed December 04, 2023).
"American Society of Hematology." Case Study: 47-Year-Old Woman With New-Onset AML and Leukostasis, 04 Dec. 2023 , https://www.hematology.org/education/trainees/fellows/case-studies/female-with-new-onset-aml-and-leukostasis .
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Journal of Education and Research in Nursing
Caring an Elderly Patient with Acute Myeloid Leukemia: A Case Study
Acute myeloid leukemia (AML) is a malign disease, characterized by the rapid growth of abnormal hematologic blood cells accumulate in the bone marrow, blood and other tissues. It is the most common acute leukemia affecting adults, and its incidence increases with age. 82 year-old married, male patient admitted to hospital about four months ago because of fatigue, inability to get out of bed and inability to walk. Patient diagnosed with AML was being cared according to Gordon’s Functional Health Patterns. Based on this model, nursing diagnosis such as ineffective airway clearance, impaired physical mobility, self-care deficit (nutrition, dressing, hygiene), imbalanced nutrition: less than body requirements, activity intolerance, impaired social activity, impaired oral mucous membrane, risk for bleeding, impaired skin integrity, risk for aspiration, risk for transmitting infection, risk for falling were diagnosed and needed interventions were applied.
Akut Miyeloid Lösemi Tanısı Alan Yaşlı Hastanın Bakımı: Bir Olgu Sunumu
Akut Miyeloid Lösemi (AML), hematolojik hücrelerin olgunlaşma yeteneğini kaybederek kontrolsüz bir şekilde çoğalması, kanda, kemik iliğinde ve diğer dokularda birikmesi ile ortaya çıkan malign bir hastalıktır. Yetişkinlerde en sık görülen ve sıklığı yaşla birlikte artan akut lösemi türüdür. 82 yaşında, evli, erkek hasta yaklaşık olarak 4 ay önce halsizlik, yataktan kalkamama ve yürüyememe şikayetleri ile hastaneye başvurdu. Akut Miyeloid Lösemi tanısı alan hastaya Gordon’un Fonksiyonel Sağlık Örüntüleri (FSÖ) Modeli’ne göre değerlendirme yapılarak gerekli hemşirelik bakımı planlandı. Bu model doğrultusunda hastaya hava yolunu temizlemede etkisizlik, fiziksel mobilitede bozulma, özbakım eksikliği sendromu (beslenme, giyinme, hijyen), beslenmede dengesizlik: gereksinimden az beslenme, aktivite intoleransı, sosyal etkileşimde bozulma, oral mukoz membranda bozulma, kanama riski, deri bütünlüğünde bozulma riski, aspirasyon riski, enfeksiyon bulaştırma riski, düşme riski hemşirelik tanıları konuldu ve gerekli girişimler uygulandı.
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