Andrew wasn’t a frequent visitor to the office. He usually came every 3 months for a prescription renewal. If he came for a longer visit, he’d often bring me a book of short stories, and complain about his wife, who he said drank too much and was very dominating! He had endured a very chaotic childhood including episodes of sexual abuse. Last year, he saw a psychiatrist for a while.
Recently, however, a routine checkup revealed some abnormal test results. Hemoglobin was decreased at 90, and platelets were at 130,000. He complained of overall stiffness, especially in the lower back and shoulders. Sed rate was 52.
His general physical was unremarkable. There was no obvious source of blood loss. He was taking multiple medications, having suffered a myocardial infarct in 1997. Now aged 53, he had remained for over 10 years on baby aspirin and clopidogrel for a stent. Other medications included digoxin, metoprolol, atorvastatin, fluoxetine, rampiril and indapamide.
He’d also seen a respirologist for COPD and was using 3 inhalators: Spiriva, Flovent, and Ventolin.
He was referred to a gastroenterologist to investigate a suspected GI bleed. Repeat blood count prompted an emergency admission. Hemoglobin was now 75, platelets 85,000. Gastroscopy showed mild hiatus hernia but no active bleeders. When queried about alcohol, he denied heavy drinking. The gastro doubted this, and wondered if the low platelet count was related to liver damage. After 3 days in hospital, he was discharged to await colonoscopy if his hemoglobin kept dropping. While in hospital, he received several units of platelets plus some blood units. Upon discharge he stood at Hgb 102, platelets 95,000.
A blood count the following week showed Hgb 82, platelets 52,000. He also told me that for the last 3 weeks his body had been covered with bruises, which hadn’t been there when I’d examined him previously.
What was going on with Andrew?
Andrew was awaiting hematologic consult but in view of the rapidly falling platelet count, I called the hematologist, leaving a message that I was stopping this patient’s clopidogrel and ASA, given that he had not suffered a cardiac event for over 10 years. The hematologist courteously called back and left me a message agreeing to this strategy. I was told that my patient was going to be readmitted that day. Later the same week, his platelets had fallen further, from 52,000 to 38,000.
He was referred to a downtown teaching hospital for bone marrow biopsy. Flow cytometry on his blood smear showed 13% blasts. The diagnosis is acute lymphocytic leukemia, etiology unknown.
Through this whole scary time, his “domineering” wife sat at his bedside supporting him.
A year later, Andrew’s in remission and doing very well. He started back at his old job 2 weeks ago. His main clinical question on his last visit concerned dandruff! Upon examination I found not a speck. Another question was how to get through to his 23-year-old daughter. I told him I couldn’t help him with that one, I have the same problem in spades.
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