CC: melena 6/26/2007

1 wk and 3 days PTA: patient noted melena for 3 days with associated pallor and generalized weakness. There was no abdominal pain, hematemesis, epistaxis, hematochezia, dizziness, and other signs of active bleeding. The pt only took 1tab of amoxicillin w/c did not provide relief of ssx.

1 wk PTA: the pt noted increased pallor and weakness and was brought to the ER.

ROS: (-) weight loss, (-) anorexia, (-) easy bruisability, (-) pallor, (+) jaundice, cyanosis(-) BOV, (-) floaters, photopsia, photophobia, inc.hearing, bleeding(-) decreased hearing sensation, (-) ear pain, ear discharge, tinnitus, bleeding(-) cold, (-) hemoptysis, (-) cough(-) PND, edema, palpitations, orthopnea, (-) bowel changes, (-) epigastric pain, (-) constipation, polydipsia, polyphagia, hematochezia, hematemesis, (+) melena(+) polyuria, (-)oliguria, nocturia, dysuria and dribbling, (-) urinary incontinence, (-) joint pains, arthralgia, myalgia

PMH: u/r

FMH: u/r

PSHx: (+) smoker, 20 pack years, (+) alcoholic beverage drinker, since ave of 7 bottles/day, (-) illicit drug use, no intake of ASA and NSAIDs

PE: BP 100/80, HR94, RR20, T36.2normal. Obliterated traube’s space. Palpable liver edge.

COURSE

1st HD: pt was pale, jaundiced, tachycardic, hyperactive bowel sounds with direct tenderness at L lateral areas. Pt was diagnosed as UGIB 2 to BPUD w/2 anemia r/o ALD. Pt was started on Pantoprazole w/c was then shifted to Omeprazole. Pt was also transfused w/ 4 u of pRBC. CBC results revealed HgB 69, Hct 0.204, Plt 779, WBC 153.5, Neut 28, Lymp 0.01, Mono 0.06, Eo 0.09, Baso 0.07, Blast 0.06, Mye 0.40, Promye 0.03, NRBC 15/100 WBC

2nd HD: pt noted relief of ssx but noted bipedal edema. Pt was continually hydrated, given NaHCO3 x TID, and was started w/allopurinol 300mg OD. BUN 2.12, Crea 124, Alb 34, TB 28.2, AST 73, ALT 90, Na 139, K 4.2, Cl 105, Ca 2.11. PT 0.77/1.17. PTT 35.4/38.6. BMA was done.

3rd HD: pt had no subjective complaints w/ E/N PE. PBS results revealed retic 0.036, mared poikilocytosis, moderated hypochromic. Some PMNs show toxic granulation, leukocytosis, immature cells (blasts, promyelocyte). NRBC noted, increased platelets. Allopurinol was started 100mg OD, and was scheduled for HAUTZ.

4th HD: pt had fever of 39.9C, stable other vitals, (+) rhonchi. Repeat cbc w/ Hgb 94, Hct0.28 WBC 122.2, Seg 54, Mono 6, Eos 10, Baso 4, Myelo 17 Blast 8 Atyplymph-1. Plt779. A> Acute Leukemia r/o HAP. Pt was started on ceftazidime 1g IV q8.

5th HD: pt had no new complaints, w e/n UA. HAUTz – hepatosplenomegaly, t/c passive congestion of the liver.

6th HD: noted mild fever and swelling at IV site (prob phlebitis). EGD findings revealed gastritis prob 2 to bile reflux, duodenal ulcer cannot r/o H pylori. Cefta d/c and started on empiric Omep 200mg BID, Amox 500mg 2 tab BID, Clarithromycin 500mg BID.

7th HD: slightly icteric sclera, no fever, and e/n PE. CBC again done w/ Hg86, Hct 0.265, WBC 161.5, Neut 0.52, lymph – 0, MCV84.0, MCH27.8, MCHC327, RDW26.9, NRBC-2, Plt876, met 0.08, stab 0.18, Mye0.01 promye 0.03 blast 0.02

Tx: Omep 20mg BID, Amox 500mg 2tabs BID, Clarithromycin 500mg BID, Lactulose 30cc OD@HS, NaHCO3 1tab TID, Allopurinol 100mg OD, Hydroxyurea 500mg 2caps TID

Final Dx: Leukemia (Acute vs Chronic)Duodenal Ulcer, t/c H. ylori

PE on Discharge:

Awae, coherent, NICRDBP 110/70, HR 80, RR 20e/n PE

Discharge Plan:

Home Meds: Hydroxyurea 500mg/cap, 2caps BIDAllopurinol 300mg/tab 1tab ODNaHCO3 1 tab TID

Follow up at Hema, w/ CBC, BMA Biopsy, LAP score and discharge summary

BMA (6/27/07)

Markedly hypercellular bone marrowmoderated granulocytic hyperplasiapresent morphologic features are compatible with a CHRONIC MYELOPROLIFERATIVE DISEASE w/ morphologic features favoring classification as CML.

BMA Genetic Testing (7/26/2007)

Confirmed Philadelphia Chromosome (9;22 translocation)