Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, which can vary but may include:
Fatigue
Easy bruising or bleeding
Petechiae (tiny red spots on the skin)
Fever or chills
Bone pain
Shortness of breath (due to bleeding complications)
Signs of bleeding (e.g., gum bleeding, nosebleeds)
History of Present Illness:
Onset and duration of symptoms
Severity of symptoms
Associated symptoms (weight loss, night sweats, loss of appetite)
Past medical history (previous diagnoses, significant surgeries)
Family history (cancer in blood relatives)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
General examination (appearance of illness, pallor)
Lymph node examination: Look for enlarged lymph nodes (cervical, axillary, inguinal)
Skin examination: Check for petechiae or other rashes
Spleen examination: Assess for splenomegaly (enlarged spleen)
Laboratory Findings:
Complete blood count (CBC):
Low red blood cell (RBC) count (anemia)
Low white blood cell (WBC) count (leukopenia) – may be normal or elevated depending on the disease stage
Low platelet count (thrombocytopenia)
Peripheral blood smear may show abnormal promyelocytes (immature leukemia cells)
Bone marrow aspiration and biopsy: Definitive test for APL, identifies the characteristic presence of abnormal promyelocytes with Auer rods (inclusions).
Cytogenetic analysis: Identifies the specific chromosomal translocation (t(15;17)) associated with most APL cases.
Molecular testing: Confirms the presence of the PML-RARA fusion gene created by the translocation.
Coagulation studies (PT, INR, aPTT): Assessed for bleeding risk.
Fibrinogen level: May be low, contributing to bleeding.
Imaging Studies:
Chest X-ray: May show signs of enlarged lymph nodes in the chest.
CT scan (optional): May be used to assess lymph node involvement and other organ enlargement.
Assessment:
Summarize the findings and diagnose acute promyelocytic leukemia (APL) based on clinical presentation, laboratory tests, bone marrow examination, and cytogenetic/molecular analysis.
Specify the presence of the t(15;17) translocation and PML-RARA fusion gene.
Describe the risk stratification group based on presenting white blood cell count and presence of additional chromosomal abnormalities.
Consider the potential complications of APL (infections, bleeding, disseminated intravascular coagulation (DIC)).
Plan:
Induction Therapy: This initial phase utilizes a combination of medications, including:
Arsenic trioxide (ATO): A cornerstone treatment for APL, targeting the abnormal PML-RARA protein.
All-trans retinoic acid (ATRA): Induces differentiation (maturation) of leukemia cells.
Consolidation Therapy: Aims to eliminate remaining leukemia cells and prevent relapse. This may involve chemotherapy or additional cycles of ATO/ATRA.
Maintenance Therapy: Aims to further reduce the risk of relapse with medications like methotrexate.
Supportive Care:
Management of infections due to compromised immune system
Blood product transfusions (red blood cells, platelets) as needed
Coagulation support (replacement of fibrinogen if necessary)
Aggressive bleeding management protocols
Specialty Consultations:
Adult hematology/oncology
Pediatric hematology/oncology (for children)
Progress Notes:
Document daily assessments including vital signs, weight, presence of infections, bleeding events, and response to treatment.
Note any changes in blood counts, coagulation studies, and other laboratory results.
Monitor for the development of the APL differentiation syndrome (a reaction to ATRA that can cause fever, shortness of breath, and fluid buildup).
Update the plan as needed based on the patient’s progress, response to treatment, and development of complications.
Discharge Instructions (for patients in remission):
Follow-up appointments with a hematologist/oncologist to monitor for relapse
Importance of maintaining good hygiene to prevent infections
Education on potential side effects of treatment
Support groups and resources for patients with APL