DIAGNOSIS: Myelodysplastic syndrome-acute myelogenous leukemia.
SUBJECTIVE: The patient returns today, now with her daughter, to review her restaging bone marrow aspiration biopsy and decide on further therapy.
She remains fatigued. She has had limited symptomatic benefit from transfusion support, on antibiotic therapy. She has a continued cough; although, her sputum is less tenacious. She has had no fever fortunately, despite deep pancytopenia. She has had no bruising or bleeding difficulties. She does have some exertional breathlessness.
She incidentally notes that Dr. John Doe subtotally excised a lesion from her left anterior chest wall, which needs re-excision. The exact nature of the malignancy is not known, but we will attempt to obtain records in that regard. Her rheumatoid symptoms have improved, and her rheumatologist has recommended that she wean off her prednisone therapy in light of her diagnosis.
She has been on prednisone 5 mg daily now for as much as 18 months. We recommended giving her 5 mg every other day of prednisone, mindful of her immunocompromised state and ultimately the benefits from coming off any immunosuppressive therapy, even at low dose.
PHYSICAL EXAMINATION: GENERAL: On exam, she is alert, lucid, and in reasonably good spirits. VITAL SIGNS: She is afebrile. Pulse is 79, blood pressure is 151/76, and weight is 140 pounds, down 5 pounds. HEENT: Reveals mild pallor. There is no icterus. No focal oral lesions. Specifically, there are no mucosal petechiae or gingival margin abnormality. LUNGS: The lung fields are clear throughout. CARDIAC: Regular without murmur. ABDOMEN: Soft without organomegaly, masses or ascites. EXTREMITIES: There is no leg edema. SKIN: No skin rashes noted.
LABORATORY DATA: The hemogram today reveals a white count of 1100. Neutrophil count is 81. Hemoglobin is 9.7. MCV 87. The platelet count is 71,000.
The bone marrow aspiration biopsy was reviewed in detail with the patient and her daughter. This reveals now a 20% blast count by histology and some 26% myoblasts by flow cytometry. This clearly represents evolution of her disease now to AML status. To continue therapy merely with the cytokine support is vastly suboptimal, and she is at imminent risk for severe opportunistic infection given severe neutropenia. She is inclined towards aggressive therapy.
Various approaches were discussed in detail to include the options of traditional AML-type induction therapy with idarubicin and ARA-C, versus topotecan and ARA-C per the MD Anderson protocol versus single agent, Mylotarg. The various toxicities, risks, and potential benefits in terms of disease control with each of these options were reviewed in detail. She wishes to proceed to aggressive induction therapy.
PLAN: Accordingly, we will arrange for a MUGA scan tomorrow to ensure adequate cardiac reserve. The chest x-ray today reveals no infiltrates and is otherwise unremarkable. We discussed her situation with Dr. John Doe, who will kindly place a triple-lumen Hickman catheter on Monday morning. She will be admitted Monday to begin induction chemotherapy. Her prognosis is appropriately guarded. She will remain on fluoroquinolone therapy until Monday to guard against febrile neutropenia and was reminded to called immediately if any temperature 100.5 degrees or higher or if any new symptoms develop.
