Possible leukemia case - seeking guidance

May 8th, 2015
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  1. Possible leukemia case - seeking guidance
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  5. ekdickmeyer
  6. Message 1 of 6 , Jun 13, 2014
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  8. Hi Everyone
  10. I have a patient who I am concerned has leukemia. I have never made this diagnosis before and am looking for guidance. This patient is un-insured and not interested in seeing a MD unless absolutely necessary.
  12. He is a 63 yo M with a recent 20 lb weight gain mostly in his abdomen, fatigue, muscle spasms/cramps, multiple lipomas over arms, abdomen, and along his spine, and bradycardia (EKG otherwise normal). He also has a 45+ yr pack history (mostly hand rolled American Spirits). We finished chelation for lead, mercury and thallium last year and at the time his labs were normal.
  13. Physical exam: no lymphadnopathy (cervical, submandibular, supraclavicular, axillary), numerous lipomas all over the body, bradycardia, possible splenomegaly, abdominal distention.
  14. Current labs (originally run in April and just repeated with similar results)
  15. WBC: 13.7 (H)
  16. Hgb: 13.9 (L)
  17. MCV: 100 (H)
  18. MCH: 33.3 (H)
  19. RDW: 14.4 (H)
  20. Platelets: 141 (L)
  21. Lymphs: 79% (H)
  22. AST: 21
  23. ALT: 21
  24. Alk Phos: 124 (H normal)
  25. Lipids normal
  27. My main concern is the elevated WBC with the lymphocytosis and thrombocytopenia. I am considering ordering flow cytometry/immunophenotyping versus going straight to bone marrow biopsy. Any suggestions for other tests or things to rule out?
  29. Also out of curiosity has anyone seen multiple superficial lipomas associated with neoplasms?
  31. Thanks,
  33. Emily Longwill, ND
  34. Ventura, CA
  37. DrDee
  38. Jun 13, 2014
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  40. Good to do an alkaline phosphatase isoenzymes testing with any alk phosphatase over 100. Also with that high of an MCV & RDW he really needs B12 & folate. Most likely injections. Also with high WBC's can be parasites, maybe SIBO, or neoplasm - perhaps further testing will assist in figuring this out before you go to a biopsy. A CT scan with contrast will give more information.
  42. Just some ideas...
  44. Dr. DeeAnn Saber, NMD
  49. Mona Morstein
  50. Message 3 of 6 , Jun 14, 2014
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  52. I would call a hemotologist for case discussion and possible referral. I'm not sure why it's come about that NDs feel they have to everything with patients, especially when the situation is new to them, and not seek helpful discussions with MD specialists in that field. I think it is very good for us, our patients, and good for our profession, to reach out to MD specialists to discuss cases when they come up with serious questioning labs, or other findings. I find when I do that the reception from the MD is excellent, and very helpful. It also expedites appropriate investigatory procedures and diagnosis for patients.
  54. Mona Morstein, ND
  55. Mesa, AZ
  57. Official Sponsor of NatChat--Doctors Data Lab
  60. Chrissy Amicone
  61. Message 4 of 6 , Jun 14, 2014
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  63. Hi Mona,
  64. Do you find you are well received when calling local medical doctors? Do you only call docs you know?
  65. I find I hesitate to call in cases like these because it feels like asking favors from a busy and reputable stranger.
  66. On another note, I would hold off on adding folate until cancer is ruled out. Also hematologic cancers are different than solid tumor cancers in many ways and certain supplements should be avoided (melatonin etc....).
  67. I would also refer to onc in this case but with the understanding that the referral is only for information gathering and nothing more.
  68. Good luck!
  69. Christina Amicone, N.D.
  70. Watertown CT
  73. Mona Morstein
  74. Message 5 of 6 , Jun 14, 2014
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  76. Hello, Christina,
  78. I call specialists I have used in the past, or that are on a list I have who have been reported to be good to work with, or who are simply close to my patient if a referral is necessary. I've referred to pulmonologists (that was SO helpful, with my first Valley Fever case with a positive x-ray; the doc led me completely through how to do appropriate treatment and follow-up over the next two years), endocrinologists (shared an Addison patient in crisis with her), gastroenterologists, hematologists; cardiologists, etc. I'm a GP; I love having the MD specialists there to help me through tough cases, and it's always a great learning experience for me.
  80. The key I think is to call and when the receptionist answers, say I am Dr. ( ) and would like to speak to Dr. SoandSo, to see if I need to refer him/her my patient. I usually get right through or hear back very quickly. I share the case, and ask for their opinion, and it's usually a very friendly, helpful call. In fact, I cannot think of a time when it went badly. Oftentimes with hematologists, it's helpful to fax the patient's blood work to them, but you can just read it over the phone to some, and they'll give advice right away. Don't worry about your ego or appearing like you don't know stuff--you really AREN'T sure what to do, so ask people who have spent a lifetime seeing patients like you have right then. I don't know a LOT; so I am eager for help when I can get it.
  82. As GP gatekeepers, I think it is very much a part of us being responsible to seek specialists when we can, when the labs or case is confusing and an MD specialist would make sense. I think there are loads of helpful, friendly MDs out there, who want to offer advice on patients, to ensure good care. After all, no doubt they got into medicine to help patients, too.
  84. And, G-d forbid, it is a very serious condition and we're floundering around a bit, trying this or that, when an MD phone call would help make a quicker diagnosis. Seems win-win to me. After all, I just diagnosed (another) patient with breast cancer last week. Things walk in our door. I've already been on the phone with the MD oncologist I referred her to; that doc is terrific. Gave me her cell phone. I feel it is a wonderful thing to be able to connect with an MD specialist when you need to.
  86. Mona Morstein, ND
  87. Mesa, AZ
  89. Official Sponsor NatChat--Doctors Data Lab
  92. Vanessa Lyon
  93. Message 6 of 6 , Jun 14, 2014
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  95. I would second Mona's advice. In Oregon, OHSU has a physician on call line Monday through Friday. You can get a doctor of ANY specialty on the phone in about 10 minutes. They even take my cell number and call me back if I can't get through. I've talked to everyone from hematologists to pediatric immunologists, and with the exception of a very unpleasant urologist last week, they have all been lovely and open.
  97. best,
  99. Vanessa Lyon, ND
  100. Portland, OR
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