BLOOD TEST RESULT (2)

SURAT RUJUKAN KE HOSPITAL AMPANG (SELEPAS BMA)
Date: 29.10.2010

 

History:

Eldest brother has bone marrow CA ~ & chemo in Penang. Pt K/C/O DM on T.MPF 250mg bd was previously admitted in September 2010 for high grade fever, chills  trigers, myalgia, arthralgia & spontaneous bleeding from gums and lips. DRT lgm detected. Had persistent thrombocytopenia and leucepenia. Completed T. Doxycycline 100mg BD x 1/52. Then in October 2010 he was electively admitted for BMAT. During his stay in October 2010, had few temperature spikes but no bleeding tendencies. Our working diagnosis was neutropenic.

Physical findings:

Sepsis. We started him on IV Tazosin 4.5g tds & IV gentamicin 80mg tds.

Traced BMA result from xxx  à non diagnostic due to inadequate

sampling but no obvious blast cells, plasma cell not raised & no megakaryocytes, FBP: thrombocytopenia maybe d/t infection/ marrow pathology.

Diagnosis:

Treat as neutropenic sepsis. TRO myeloma.

Result of investigation:

ANA & LE cells: negative

WBC: 1.1-5.1

ESR: 108

Coombs direct & indirect: negative.

PLT: 29-98

Wine protein electrophoresis: Pending (sent to IMR on 12.10.2010)

Purpose of referral:

For second opinion & further management

BLOOD TEST RESULT                    

Date	30/9	30/9	1/10	5/10	5/10	6/10	7/10	7/10	8/10
HB	12.0	17.9		11.3		12.7	12.3	12.3	12.4
TWDC	1.8	5.1		1.8		1.5	2.0	1.3	1.1
PLATELETS	43	98		42		37	37	44	38
ESR						105
UREA				3.9	3.4	3.3			2.9
SODIUM				142	139	135			138
POTASSIUM				3.3	3.9	4.3			3.5
CREATININE				72	54	70			78
T.PROTEINS						98			95
ALBUMIN						30			30
GLOBULIN						68			65
T.BILIRUBIN						13			15
AG ratio						0.4			0.5
ALT						118			107
ALP						86			95
URIC ACID						193			184
PT		17.0	19.3	19.3	18.5	17.9	17.4
APTT		50.5	38.5	38.5	46.0	50.0	50.0
INR		1.49	1.30	1.70	1.60	1.54	1.48
LE cells	-ve
Coombs	-ve
ANA	-ve

INVESTIGATION CHART, JABATAN PERUBATAN xxx

lxs/date	10/10	10/10	12/10	12/10	13/10
TWC		1.3	1.8	1.2	1.4
Hb		12.7	12.3	11.6	11.5
Hct			35.4	34.6	32.1
Plt		32	33	29	33
Urea	3.4	2.9	3.2
Na	139	136	139
K	3.5	3.2	3.5
Chloride	104	106	106
Creat	64	73	71

AHP: Maaf kalau ada banyak kesilapan istilah. Memang susah nak faham tulisan doctor. Maklumat ini sebenarnya bagaikan mendedahkan kelemahan diri kepada umum tetapi aku bersikap positive (aku kan HIV positive!) demi kajian klinikal.