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ЗмістII. Learning Objectives
IV. Theory Topics on the Subject
Additional investigation findings
Chronic Leucoses Classification
M. Gorky Donetsk National Medical University
Methodic guidelines for the 6th year students
Self-training on the practical study
at the Internal medicine # 1 department
Donetsk – 2010
Authors: N.T. Vatutin, N.V. Kalinkina, E.V. Keting
R.V. Basiy, MD, PhD, anatomy department.
T.A. Parkhomenko, MD, PhD, internal medicine # 2 department.
I. Importance of the Subject.
Chronic leucoses are the most common hemoblastoses in the countries of Europe and North America. So, the incidence of the chronic lymphatic leukemia (CLL) is 30%, and that of the chronic myeloleukemia (CML) is 20% of the total leucosis incidence rate. The annual CLL morbidity rate in these countries ranges up to 3-3.5 in 100,000 population, representing 9% of all malignant tumors. As for CML thise figure range within 1-1.5 in 100,000 population.
In order to master the subject, knowledge of anatomy, histology, normal and pathological physiology of the hemopoiesis system, as well as propaedeutics of internal diseases, pharmacology and clinical pharmacology are required.
Changes in the blood analysis, lymphadenopathy and hepatosplenomegaly are syndromes typical of many hundreds of the diseases concerning various branches of medicine. According to the above, it is of a special importance for the doctor to have skills in making a correct differential diagnosis of the diseases, accompanied by these syndromes. Thus, taking into account difficulties of diagnosing chronic leucoses, the patients suffering from this pathology can be encountered in medical practice of any specialty.
If the importance of the subject has been understood, proceed to studying the learning objectives.
Key objective: to develop skills in making a differential diagnosis of chronic leucoses, and planning a patient management.
The information necessary for reviewing and revising the basic knowledge and skills can be found in the following references:
Pre-Practice Knowledge and Skills Test Questions
Q1. A 63-year-old patient, has her cervical and axillary lymph nodes palpated that are as big as 2 cm in diameter, the liver sticks out as far as 3 cm, and the spleen does as far as 5 cm from under the edge of the costal margin. The blood count presents the following evidence: erythrocytes are 3.5×1012, Нb is 143 g/l, color index is 1.0, thrombocytes are 198 g/l, leucocytes are 38.6 g/l, 2 band neutrophils, 9 segmented neutrophils, 3 prolymphocytes, 85 lymphocytes, 1 monocyte, and ESR is 19 mm/h. Which of the following syndromes is the one described in this case?
Q2. The general blood count of a 29-year-old patient showed the following data: erythrocytes were 3.7×1012, Нb was 122 g/l, color index was 1.0, thrombocytes were 109 g/l, leucocytes were 8.3 g/l, 1 eosinophil, 1 basophile, 4 band neutrophils, 58 segmented neutrophils, 32 lymphocytes, 4 monocytes, and ESR was 14 mm/h. Which of the following can be a correct diagnosis?
Q3. The white blood cell count of a 49-year-old patient showed the following changes: 1% basophiles, 2% eosinophils, 2% band neutrophils, 42% segmented neutrophils, 50% lymphocytes, and 3% monocytes. Which of the following is an appropriate name for these changes?
Q4. The doctor prescribed hemoexfusions with a subsequent compensation of the circulating blood volume to a 55-year-old patient affected by Osler's disease. Which of the following was supposed to be used with this object in view?
Q5. A 32-year-old patient taking 80 mg dose of prednisolone per day as a constituent of one of her polychemotherapy regimen noticed an increased body weight, appearance of striae atrophicae on the skin of her thighs and abdomen, hair growing on her face, and along the white line of her abdomen. Which of the following syndromes occurred as a complication of glucocorticosteroidal therapies administered to this patient?
To reach the learning objectives it is essential to master the following theory issues:
The information necessary for mastering the theory issues may be found in the following references:
Then, proceed to solving some test questions.
Q1. The general blood count of a 33-year-old patient complaining of a low grade fever is the following: erythrocytes are 2.5×1012, Нb is 86 g/l, color index is 1.0, thrombocytes are 72 g/l, leucocytes are 1.9 g/l, 1 band neutrophil, 9 segmented neutrophils, 88 lymphocytes, 2 monocytes, and ESR is 20 mm/h. Which of the following changes have been registered?
Q2. A 52-year-old patient presents a purple-cyanotic color of his skin, elevation of BP up to 180/100 mm Hg, enlargement of the spleen (+4 cm from under the edge of the costal margin). The blood test showed the following data: erythrocytes were 6.2×1012, Hb was 206 g/l, color index was 1.0, thrombocytes were 580 g/l, leucocytes were 11.3 g/l, 3 eosinophils, 8 band neutrophils, 74 segmented neutrophils, 15 lymphocytes, 4 monocytes, and ESR was 2 mm/h. Which of the following methods will be of crucial importance for refining the diagnosis?
Q3. The general blood count of a 46-year-old patient being under observation on account of essential hypertension showed the following findings: erythrocytes were 6,9×1012, Hb was 210 g/l, color index was 1.0, thrombocytes were 620 g/l, leucocytes were 18.7 g/l, 1 eosinophil, 5 band neutrophils, 65 segmented neutrophils, 25 lymphocytes, 4 monocytes, and ESR was 3 mm/h. The evidence presented gives grounds to assume the Osler's disease. Which of the following diseases must first be diagnosed on a differential basis?
Q4. A 40-year-old patient complains of a general weakness, a low-grade fever for 2 months, a heavy sensation in the left hypochondrium, and enlargement of the spleen (sticking out as far as 8 cm from under the edge of the costal margin). The blood count shows the following: erythrocytes 3.0×1012, Hb is 95 g/l, color index is 1.0, thrombocytes are 170 g/l, leucocytes are 127,5 g/l, 2 eosinophils, 3 basophiles, 2 promonocytes, 7 myelocytes, 12 metamyelocytes, 8 band neutrophils, 62 segmented neutrophils, 3 lymphocytes, 1 monocyte, and ESR is 25 mm/h. Which of the following is the most probable diagnosis?
Q5. A 60-year-old patient diagnosed to have a chronic lymphoid leucosis for the first time, manifests enlargement of the peripheral lymph nodes of all groups up to 1-1.5 cm in diameter, the blood count reveals the following: erythrocytes 4.0×1012, Hb is 140 g/l, color index is 1.0, thrombocytes are 220 g/l, leucocytes are 21,6 g/l, 1 eosinophil, 2 band neutrophils, 9 segmented neutrophils, 5 prolymphocytes, 81 lymphocytes, 2 monocytes, and ESR is 17 mm/h. Which of the following patient management techniques is preferable?
Teaching Guidelines for Practice Activities on Chronic Leucoses
At the beginning of the class, the instructor gives a test to check and correct the pre-practice level of knowledge. Then, the students start to see patients under the instructor’s supervision after which the students give an analysis of the practice patients and the instructor checks the mastering of the practice topics. A final test is provided to strengthen the knowledge gained. At the end of the class, the instructor reviews the students’ self-learning activity, considers and corrects the students’ typical mistakes with a subsequent improvement of knowledge and skills.
Flow Chart of Chronic Leucoses
Women 115-145 g/l
Men 130-164 g/l
(Hb/erythrocytes х 30)
Women 4-16 mm/h
Men 2-10 mm/h
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