NARRATIVE PATHOPHYSIOLOGY

On November 15, 2015, Patient XYZ was diagnosed with cancer of the blood
and the spongy tissue that produces the blood cells or also known as the bone marrow,
this diagnosis is also known as Acute Myelogenous Leukemia or AML. This disease
results from a defect in the hematopoietic stem cell that differentiates into all myeloid
cells: monocytes, granulocytes (neutrophils, basophils, eosinophils), erythrocytes, and
platelets. AML is also the most common non-lymphocytic leukemia.
Certain risk factors influence the onset of the disease. Predisposing factors
would include age of five years old and the male gender which are considered to be
some factors that may cause the mutations in the hematopoietic stem cells in the bone
marrow. Other factors that could precipitate the disease include chemical exposure from
the living areas of the patient which causes alterations in genetic structure of stem cells.
The disease process starts with the alteration of the cells DNA structure caused
by the said factors. Proto-oncogenes, which are responsible for normal metabolic
processes in the body, are transformed to oncogenes - which are mutated genes which
serve no purpose in the body. There will be mutation of tumor suppressor genes which
are responsible for normal cell cycle and replication. This will lead to over expression of
growth factors that are necessary for cellular growth and proliferation. Normal cellular
functioning will be altered such as transcription and translation process. Due to
mutation, the cells error detection and correction mechanism is dysfunctional causing
production of more mutated cells. There will be uncontrolled cell cycle and cell division
due to the dysfunction in regulatory mechanisms. Since the bone marrow is the affected
site, there will be formation of neoplastic cells from mutated multi-potent stem cells. In
AML, the affected precursor cells are the myeloblast which differentiates to monocytes,
granulocytes (neutrophils, basophils, eosinophils), erythrocytes, and platelets. Due to
mutation, myeloblasts are in a state of differentiation arrest which renders them unable
to differentiate and mature. There will be clonal expansion of these myeloid precursors
since they still have the ability to proliferate but in an abnormal rate. These malignant
cells are insensitive to apoptotic cell death or programmed cell death. Accumulation of
neoplastic cells occurs in the bone marrow causing bone marrow expansion. Normal

bone marrow cells will be crowded by the malignant cells causing destruction and bone
marrow suppression. There will be alteration in hematopoiesis, the process of formation
of blood components. And then there will be formation of dysfunctional blood
components causing premature destruction and loss of their function.
During 30th of November 2015, he underwent a CBC test with given back in
alarming outcomes. There is a decrease in RBCs which read 2.19 X 1012/L, a decrease
of hemoglobin of 6.30 g/dL, an increase of leukocytes of 56.9 X 109/L, and a severe
decrease of platelets which read 29 X 109/L. With these results doctors made out
Anemia, Monocytopenia, and Thrombocytopenia
Anemia is a condition where there is a decline in erythrocyte concentration and
with an accompanying decrease in hemoglobin levels. Erythrocytes and hemoglobin are
important in the transportation of nutrients and oxygen to tissues and organs.
Decreased levels would result to weakness, pallor, and splenomegaly due to low
oxygen levels needed for metabolic processes. Treatment for anemia would include
blood transfusion to replace dysfunctional RBCs, and dietary supplements of Zinc
Sulfate Syrup (E-Zinc) 5ml PO OD 6pm by which was prescribed to the patient to
stimulate the bone marrow to produce RBC.
Monocytopenia results from decreased production of circulating monocytes in the
blood and there is diminished ability to destroy bacteria through phagocytosis..
Monocytes are responsible for the phagocytosis in the cell by surrounding and engulfing
the bacteria. Decrease in monocyte count could lead to increased risk for infection and
may cause further complications.
Thrombocytopenia is a result of decreased platelet count in the blood. Platelets
may also exhibit diminished ability to aggregate during blood clotting and are less
adhesive. Platelets are responsible for blood clotting process in the presence of injury
to the skin and other membranes. Thus for treatment Patient XYZ was seen by the
admitting physician and was ordered to undergo blood transfusion for the treatment of
both the anemia and thrombocytopenia. 30 minutes prior to transfusion the patient was
administered Diphenyhydramine hydrochloride (Benadryl) 12.5mg/5ml, 5ml. About

296ml on the November 30 th was transfused. A couple minutes after due to

hypersensitivity from the blood transfusion, the temperature of Patient XYZ went up to
about 38-39 degrees Celcius and was administered PRN PCM (Biogesic) 250mg/5ml,
4ml, Q4, PO to help lower down the temperature.
As the AML disease continues, it begins to metastasize. There will be continuous
proliferation of malignant leukemic cells in the bone marrow. Damage to surrounding
blood vessels occurs due to overcrowding of malignant cells and there will be entry into
the circulation. These malignant cells could lodge to different organs and invade normal
cells. They could invade the lymph nodes, spleen, and liver, and will cause
lymphadenopathy, splenomegaly, and hepatomegaly which would cause abdominal
discomfort and distention.
As chemotherapy for the Acute Myelogenous Leukemia, the admitting physician
ordered blood transfusion of 296ml on the 4 th of December, started at around 10 am and
ended at 2:20 pm.
During the course of the metastasis, the patient develops Pneumonia and Acute
oral thrush or better known as Oral Candidiasis.
Several factors are considered factors that may have triggered the patient to
develop Pneumonia. The predisposing factors that are evident is the young age of the
patient, and the gender as males are more likely to develop the disease. The
Precipitating factors are then the immature immune systems and the small airways of
the child.
Pneumonia first starts out as the virulent microorganism, Streptococcus
pneumoniea a Gram positive bacteria enters the nose and passes down into the larynx
continuing through pharynx and trachea until it reaches the airway and lung
parenchyma and starts to affect it. As the infection starts, airway damage and lung
invasion occurs. For the airway damage, it then infiltrated the bronchi lodging
stimulations in the bronchioles causing the alveolar to collapse which would then
increase the pyrogen percentage in the body ultimately leading to fever with the
temperature of 38 to 39 degrees Celsius which would then be medicated with

Paracetamol 250mg/5ml 4ml Q4 PRN. On the other hand, after the lung invasion,
flattening of the epithelial cells would occur leading to two circumstances first of which is
the mucus and phlegm production by the macrophages and leukocytes causing the
patient to have productive cough with hard and greenish coloured phlegm which was
medicated with Piperacillin-Tazobactam (Vigocid) 900 mg IV Drip, Q6, ANST (-)12 MN
6 AM 12 NN 6 PM and Clindamycin (Cleocin Pedia) 75mg/5, 5ml, PO, QID 8AM
12NN 4PM 8PM. The second of which is the decrease in the red blood cells with the
laboratory and diagnostics results of 2.84x1012/L causing body malaise by the patient.
Oral Candidiasis starts with the predisposing factors of age of five years old and
the precipitating factors of a weakened immune system and antibiotic therapy. First the
normal flora of the mouth is disrupted with the CD4 cell count dropping below 350 the
microorganism Candida albican then causes an overgrowth of yeast on the oral mucosa
causing the desquamation of epithelial cells thus leading to the accumulation of
bacteria, keratin, and necrotic tissue. Because of the disease oral mucosal lesions are
found in the patients mouth which are then treated with Nystatin (Mycostatin) Syrup
(suspension) 1ml, Swish and Swallow, TID 8AM 1PM 6PM.
During the course of treatment for all the diagnosiss the drugs that were used to
medicate had a side effect of Diarrhea which became one of the problems. That drugs
that induced the side effect were Piperacillin-Tazobactam (Vigocid), Nystatin
(Mycostatin), and Clindamycin (Cleocin Pedia). This started by drugs disrupting the
normal flora in the intestines, increasing the number of the flora around. This shift of
normal levels directly leads to the development of gastrointestinal problems. This then
leads to the ineffective bowel movement and activity of the patient leading to the
decrease of absorption of fluids in the large intestines thus soft stools were noted. The
admitting physician was notified and Patient XYZ was prescribed Racecadotril
(Hidrasec) 10 mg sachet 1 sachet per 10 ml H20, PO, TID 8AM 1PM 6PM.