The Payle family have been your patients since the couple married and Mrs. Payle has brought her daughter and son in to you regularly since they were born. She tends to fuss over her children and, on occasion, can be quite demanding. Today is one such occasion. She has pressured your receptionist for a 'fit-in' appointment for Jimmy who is now four years old. As you enter the room Mrs. Payle announces: "Doctor you have to give me some antibiotics for Jimmy!"
The last time you saw Jimmy was two weeks previously when he was treated for a urinary tract infection. Mrs. Payle indicates that, since then, Jimmy has been lethargic, irritable and whiny and particularly in the past three days when he also seemed to have a mild fever. On questioning, Mrs. Payle recalls that Samantha, Jimmy's 6-year-old sister, has been complaining "off and on" of a sore throat but she continues to have lots of energy and go to school.
Jimmy is alert and cooperative on physical examination. He appears pale but is in no obvious distress. He is 101cm tall and weighs 17kg. Temperature is 38.5°C. Blood pressure is 92/56 mmHg. Heart rate is 130/min. Respiratory rate is 24. You are able to palpate several cervical lymph nodes. The liver border is palpated below the costal margin. You think that you can feel the spleen. Jimmy's chest is clear on auscultation. His neurological exam is normal. You already know that Jimmy has no known allergies. Besides the liquid Tylenol his mother gave him last night, he is not taking any medications.
You suspect that Jimmy might have infectious mononucleosis and/or a streptococcal throat infection. You wonder about prescribing penicillin but take a throat culture and also arrange for Jimmy to have some laboratory investigations and to return for a follow-up appointment to reassess the patient and discuss the results.
The next morning, the lab calls with some abnormal results on Jimmy. His WBC is 32 000 and there are many blast cells in the blood smear. You call Mrs. Payne and ask her to bring Jimmy in the afternoon. When they arrive, Jimmy is much the same, but Mrs. Payne is very anxious. You review the results of the CBC and peripheral blood smear. You inform her that the laboratory results combined with the history and physical findings are suggestive of acute lymphocytic leukemia. Jimmy's mother is very distressed and starts to cry. She has many tearfus questions:
- What exactly is leukemia?
- How did the leukemia start?
- Is my daughter at risk of developing it?
- Will Jimmy die from his disease?
- How will Jimmy be treated?
- When will the treatments begin?
- Will Jimmy have to go to the hospital?
- Are there side effects from treatment?
After addressing her concerns as best you can, you refer Jimmy to a pediatric haematologist/oncologist at the regional cancer centre.