Hematology and Respiratory Clinic

I spent today in the hematology and respiratory clinics.  I really enjoyed the hematology clinic.  The consultant took the time to fill me in on the patient and do the exams on pts with clinical findings.  The first case was of a child with suspected ITP.  Her platelet count was 7.  She had a bone marrow biopsy which unfortunately showed dysplasia.  So the visit today the consultant explained the bone marrow findings to the mother.  It was very interesting the the consultant did not get into details about the worse possible implications of bone marrow dysplasia.  Instead, she said that it may get better or it may get worse and for now we are going to focus on preventing injuries that would lead to bleeding (including bike riding, poor kid!), and continue to monitor her counts.  I thought this was a great way to handle the meeting because as the consultant said, there is nothing that would change management now even if the dysplasia turned out to be progressive.  And if she had started mentioning all the severe outcomes the mother would not have been able to focus on what she can do now to keep her child healthy.

We next saw an intersting patient with severe sickle cell that kept having crises.  Unfortunately during 2 transfusions he hemolyzed and developed hematuria.  The visit focused on the next step in managment for him: either hydroxyurea (which he didn't respond well to in the past) or another transfusion.  We looked at a CXR from a recent hosptial admission.  The first CXR showed some infiltrates in the LL lung field.  A repeat CXR taken 12 hrs laters showed almost complete white out of one half of the right lung field.  I was so shocked to see how fast his acute chest syndrome progressed.  She asked me to examine the patient and when I did I felt his liver without knowing before hand it was enlarged.  I wasn't expecting it to be either.  So I was really happy that what I thought was going to be another routine abdominal exam I actually picked up that his liver was enlarged.  When she asked about my exam I told her I felt it about 3 cm below the subcostal angle and she said she agreed. 

During respiratory clinic in the afternoon I saw intersting cases.  One was a child with transposition of the great vessels, surgically corrected, now with pulmonary hypertension.  Another was a child with Leigh's disease with decreased respiratory function.  The consultant didn't involve me much though and I didn't know anything about the pt when they came in so it was pretty boring.