Introduction of the Client

A 16 year old Malay boy, named Mohammad, presented to the emergency department of General Hospital Malacca on 07 January 2011 at 10 27 AM !ith fe"er, #oint pain and loss of appetite$ He !as accompanied by his mother$ His mother said that his fe"er !as on and off for the last 2 months and !ith episode of high grade fe"er for 2 days in a !ee%$ &ased on his mother's statement, Mohammad did not e(perience bleeding, any cough, upper respiratory tract and urinary tract infections symptoms and diarrhoea$

Physical Examination
)n e(amination, Mohammad sitting blood pressure !as 1*6+6, mmHg, his pulse rate !as 112 bpm and body temperature !as *,-.$ Mohammad !as alert, conscious, can spea% in full sentences, pale, and not tachypneic$ He has no palpable lymph node$ /espiratory has clear and e0ual air entry, .12 sho!ed 3ual /hythm 4o Murmur, abdomen soft, non5tender and a palpable spleen of about 6cm$ and his .42 !as grossly !ea%$

Diagnosis
&ased on the clinical in"estigation and physical e(amination, Mohammed !as diagnosed !ith Acute 7ymphocytic+lymphoblastic 7eu%aemia 8A779$

Management Plan
:pon admission, the physician ordered ;1 <a=ocin 6$>G <32, ;1 infusion of 2 pint 3e(trose 2aline in 26 hours and ?&. test for repeat$

Medical History
<!o months ago Mohammad !as admitted to Hospital @utra, Malacca$ His complaint !ere tiredness 8for 1 month9, pale, fe"er and s!elling on both hands$ &ased on the blood test results, his physician diagnosed him !ith acute lymphocytic+lymphoblastic leu%aemia$ 2ince birth he has no other health complaints e(cept the current diagnosis$

Surgical History
4o surgical history$

Family History
Mohammad's father, a pensioner, told to ha"e diabetes mellitusA his mother, a house!ife, has hypertension !hile the rest of the family are healthy$ <he family claimed to ha"e no history of malignancy$

Social History
Mohammad is currently staying !ith his parents and 1 sister$ He is a form > student in one of the go"ernment school of Malacca$ He lo"es to play football in school and play !ith his friends in the afternoon after class$ He also lo"es to #og before playing any ballgames$ He is the youngest among the 6 siblings in the family, 2 of them are married and are staying on their o!n$

Food and Drug Allergies

Mohammad has no %no!n allergies$

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

ACUTE !MPH"C!TIC EU#EMIA $A Introduction of the Disease

7eu%aemia 8also %no!n as B!hite bloodC9 is a group of chronic malignant disorders of !hite blood cells and !hite blood precursors$ ;t is characteri=ed by replacement of bone marro! by malignant immature !hite blood cells, abnormal immature circulating D&.s, and infiltration of these cells into the li"er, spleen, and lymph nodes throughout the body 87eMone and &ur%e, 200,9$ Physiology Review Most blood cells are formed in the bone marro!, (the soft material in the center of most bones) called stem cells& 2tem cells mature into different %inds of blood cells of !hich each %ind has special functions a$ 'hite (lood cells (also called WBCs or leukocytes9, help the body fight infections and other diseases$ b$ )ed (lood cells (also called RBCs or erythrocytes9 carry o(ygen from the lungs to the body's tissues and ta%e carbon dio(ide from the tissues bac% to the lungs$ <he red blood cells gi"e blood its colour$ c$ Platelets 8also called thrombocytes9 help form blood clots that control bleeding$ 4e! or immature blood cells are called blasts$ 2ome blasts stay in the marro! to mature !hile some tra"el to other parts of the body to mature$ Dhen the blood cells gro! old or get damaged, they die, and ne! cells !ill form again$ <his picture sho!s ho! stem cells mature into 2 different types of !hite blood cells$
a. A myeloid stem cell matures into a

myeloid blast, !hich further differentiate into granulocytes, neutrophil, eosinophil and basophils$
b. A lymphoid stem cell matures into a

lymphoid blast !hich further differentiate into lymphoid tissue such as & cells and < cells$ 7eu%emias are classified based on ho! 0uic%ly the disease de"elops and gets !orse$ ;t can be either chronic 8which usually gets worse slowly9 or acute 8which usually gets worse quickly9

Case Study on Acute Lymphocytic Leukemia

a. Chronic leu*emia$ ;t is characteri=ed by an abnormal mature5appearing cell$ b. Acute leu*emia$ ;t is characteri=ed by a rapid disease progression and immature

or undifferentiated blast cells$ <hey are aggressi"e tumors that reach a clima( !ithin fe! !ee%s or months$ <he types of leu%emia also can be grouped based on the type of !hite blood cell that is affected, namely lymphoid cells or myeloid cells
a.

ym+hocytic 8or lymphoblastic) leu*emias in"ol"e immature lymphocytes and their precursor cells in the bone marro!$ ;t also penetrates the spleen, lymph nodes, .42 and other tissues$ Acute lym+ho(lastic leu*emia 8ALL9 is most common in children !hile chronic lym+ho(lastic leu*emia 8CLL9 affects older adults$ <his in"ol"es the myeloid stem cells in the bone marro!, inter"ening !ith the maturation of all types of blood cells, including granulocytes, /&.s, and thrombocytes$ <his affects mostly on adult people$ Acute myeloid leu*emia $AML9 commonly affects in children and young adults and is usually associated !ith to(ins, genetic disorders and treatment of other cancers & Chronic myeloid leu*emia (CML9 on the other hand, affects primarily adults$

b. Myeloid $also known as myelogenous, myelocytic or myeloblastic% leu*emia&

Patho+hysiology
Acute lym+hocytic leu*emia $A % is characteri=ed by e(cessi"e accumulation of lymphoblasts 8immature lymphocytes9 in the bone marro!, lymph nodes, and spleen as !ell as in the circulating blood and fails to function effecti"ely as normal blood cells to maintain immunity$ 7ymphoblasts stop the normal bone marro! production of red blood cells, platelets and mature leucocytes resulting to thrombocytopenia, leu%openia, and anemia$ Dithout treatment, the client may die of infection or haemorrhage$

Bone marrow aspirate from a child with B-precursor acute lymphoblastic leukemia. The marrow is replaced primarily with small, immature lymphoblasts.

;n most cases, A77 result from altered e(pression of genes !hose products contribute to the normal de"elopment of & cells and < cells$ ,0E cases of !hich results from malignancy

Bone marrow aspirate from a child with T-cell acute lymphoblastic leukemia. The marrow is replaced with lymphoblasts of various sizes.

Case Study on Acute Lymphocytic Leukemia

transformation of & cells !hile 20E from < cells$ ;t is most common in children, representing nearly one third of all paediatric cancer cases$ <he annual incidence is appro(imately F510 cases per 100,000 populations in childhood$ <he pea% incidence occurs in children aged 25> years 8Di%ipedia9$ ;n adults, A77 is rarely seen until late middle age people !here its incidence increases !ith aging$

Predis+osing Factors
<he e(act cause of leu%emia is not clear$ Ho!e"er, fe! ha"e been associated !ith an increased ris% of de"eloping the disease, to !it
)adiation @eople e(posed to "ery

high le"els of radiation are much more li%ely than others to get acute myeloid leu%emia, chronic myeloid leu%emia, or acute lymphocytic leu%emia$

Atomic bomb explosion (World War II) people, especially children, who sur!i!e during atomic bomb e"plosions, are at increased risk of leukemia#

Radiation therapy medical treatment for cancer and other conditions# Diagnostic x-rays $"posure to much lower le!els of radiation e#g#, dental "%rays and other diagnostic "%rays ( CT scans)# &owe!er, research study is still on

going to confirm the link of "%rays and leukemia#

Chemothera+y .ancer patients treated !ith certain types of cancer5fighting drugs

sometimes later get acute myeloid leu%emia or acute lymphocytic leu%emia e$g$, al%ylating agents or topoisomerase inhibitors is lin%ed !ith a small chance of later de"eloping acute leu%emia$
Do,n Syndrome and Certain "ther Inherited Disease increase the ris% of acute

leu%emia$

Clinical Manifestations
eu*emias, li%e other blood cells, tra"el through the body !here it influences the health and function of all organs and systems$ 2ymptoms may "ary from one person to another, depending on the number of leu%emic cells and !here these cells collect in the body$ &ut generally, manifestation of leu%emia results from anemia, infection and bleeding$ <hese include pallor, fatigue, tachycardia, malaise, lethargy, and dyspnoea on e(ertion$

Case Study on Acute Lymphocytic Leukemia

;nfection may cause fe"er, night s!eats, oral ulcerations, and fre0uent or recurrent respiratory, urinary, integumentary or other infections$ ;ncreased bleeding is due to thrombocytopenia$ )ther manifestations results from leu%emic cell infiltrations, increased metabolism and increased leu%ocytes destruction$ ;nfiltration of the li"er, spleen, lymph nodes and bone marro! causes pain and tissue s!elling in the in"ol"ed areas$ Meningeal infiltration causes increased intracranial pressure that leads to headache, altered le"el of consciousness, cranial ner"e impairment, nausea and "omiting$ ;nfiltration of the %idney may affect renal function, !ith decreased urine output and increased blood urea nitrogen and creatinine$ ;ncreased metabolism causes heat intolerance, !eight loss, dyspnoea on e(ertion, and tachycardia$ 3estruction of large numbers of D&.s releases substantial amounts of uric acid into the circulationA uric acid crystals may obstruct renal tubules, causing renal insufficiency$ Ta(le -& .eneral Signs and Sym+toms of A P"SSI/ E
?e"er 7oss of appetite Joint+&one pain Dea%ness 2pleen enlargement 8splenomegaly9 Hepatomegaly ;nfection 8sepsis9 3yspnoea on G(ertion &leeding

P)ESE0TED /! THE PATIE0T ?e"er 7oss of appetite

Joint+&one pain Dea%ness 2pleen enlargement 8splenomegaly9

Hepatomegaly 2epsis

Anemia Headache 1omiting .onfusion 1isual disturbance 2ei=ure 7ymphadenopathy

Anemia

Case Study on Acute Lymphocytic Leukemia

Gle"ated D&.s

Gle"ated D&.s

)f the signs and symptoms listed abo"e, Mohammad's only sho!ed fe"er, loss of appetite, bone pain, !ea%ness, sepsis, anemia, ele"ated D&.s and spleen and li"er enlargement of about 6 cm and > cm, respecti"ely$

Clinical In1estigations
<he follo!ing clinical in"estigations are ordered !hen patient is suspected of leu%emia
Physical exam .hec%s for s!ollen lymph nodes, spleen, or li"er$ /lood tests .omplete blood count to chec% the number of !hite blood cells, red blood

cells, and platelets$ 7eu%emia causes a "ery high le"el of !hite blood cells$ ;t may also cause lo! le"els of platelets and haemoglobin, !hich is found inside red blood cells$ /io+sy /emo"al of tissue of the bone marro! in the hipbone or other large bone to loo% for cancer cells$ ;t is the only !ay to %no! !hether leu%emia cells are in the bone marro!$ <here are t!o !ays ho! to obtain sample of the bone marro!, some physician do both at the same time
1. /one Marro, As+iration <he doctor uses a thic%, hollo! needle to remo"e samples

of bone marro!$
2. /one Marro, /io+sy& <he doctor uses a "ery thic%, hollo! needle to remo"e a

small piece of bone and bone marro!$

um(ar Puncture A procedure used to collect cerebrospinal fluid from the spinal column$ A long, thin needle is inserted into the lo!er bac% belo! the le"el of spinal cord and fluid is aspirated$ ;f the treatment is for .42, after aspiration of fluid, chemotherapy is in#ected into the spinal canal$ <his procedure is done from time to time to chec% if leu%emic cells are being %illed and to gi"e more doses of chemotherapy$ 2ometimes both chemo and radiation therapies are used$

Case Study on Acute Lymphocytic Leukemia

 Chest

x2ray ;t sho!s s!ollen lymph nodes or other organs and bones inside the chest$

?or Mohammad, the clinical in"estigation !ere purely blood test because he himself and his mother !ere not %een on bone marro! aspiration, !here his doctor recommended to do for further in"estigation of his case$

Treatment
@atients !ith acute lymphocytic leu%emia ha"e se"eral treatment options, e$g$, chemotherapy, radiation therapy, !atchful !aiting, targeted therapy, biological therapy, and stem cell transplant$ ;f your spleen is enlarged, your doctor may suggest remo"al$ 2ometimes a combination of these treatments is used$
Chemothera+y$ <his is the treatment choice of most types of leu%emia, !ith a goal of

eradicating leu%emic cells and producing remission$ .hildren !ith this disease are li%ely to be cured and a number of adult patients ha"e high remissions$ Generally, chemotherapy is di"ided into 2 phases induction phase therapy and post5 remission therapy$
a. Ind ction Phase! 'uring this phase drugs doses are high to eradicate leukemic cells

from the bone marrow# ( combination of drugs is used such as daunorubin (cerubidine, an antitumor antibiotic) with !incristine (onco!in, a plant alkaloid) with prednisone with asparaginase (elspar)# )hese high doses of drug often damage the stem cells and interfere with the production of normal blood cells but circulating mature blood cells are not affected because they are no longer di!iding# )he degree of bone marrow suppression is influenced by the number of factor e#g#, age, nutritional status* current chronic diseases (impaired li!er or renal function, drug and drug dose and prior treatment#Colony%stimulating factors (C+,s), also called hematopoietic growth factors, and often are administer to rescue the bone marrow following the induction of chemotherapy# C+,s are cytokines that regulate the growth and differentiation of blood cells#
b. Post-remission "herapy! -nce remission is achie!ed, post remission chemotherapy is

continued to eradicate any additional leukemic cells, pre!ent relapse, and prolong sur!i!al# ( single chemotherapy agent, combination therapy or bone marrow transplant may be used for post remission treatment (.e/one 0 Burke, 1223)#
)adiation Thera+y 8also called radiotherapy9 uses high5energy rays to %ill leu%emia

cells$ /adiotherapy damages cellular 34A$ <hough the leu%emic cells continue to function, it cannot di"ide and multiply e$g$, cells in bone marro! and cancer cells di"ides rapidly and respond 0uic%ly to radiation therapy$ /adiotherapy is also aimed at the spleen, the brain, or other parts of the body !here leu%emia cells ha"e collected$

Case Study on Acute Lymphocytic Leukemia

 /one Marro, Trans+lant $/MT%$ <his is often used in con#unction !ith chemotherapy

or radiation$ <here are 2 categories

1. Allogenic #M"! 4ses the bone marrow of a healthy donor (usually from a

sibling5unrelated closed matched antigen# )he donor6s bone marrow is aspirated and is infused through a central !enous line into the recipient#
2. A tologo s #M" (or bone marrow resc e$! 4ses the client own bone marrow to

restore the bone marrow function after chemotherapy or radiation# 'uring the period of disease remission, about 7. of bone marrow is aspirated from the patient# It is then stored and fro8en for use after treatment of chemotherapy or radiation, with the aim of destroying the immune system and malignant cells and to prepare space in the bone marrow for new cells# )he filtered bone marrow is thawed and infused intra!enously through central line and slowly become part of the client6s bone marrow, neutrophil count increases, and normal haematopoiesis takes place#
Allogeneic Stem Cell Trans+lant& ;s a replacement of the recipients blood cell lines

8D&.s, /&.s, and platelets9 !ith cells deri"ed from the donor stem cells$ <his is an alternati"e to bone marro! transplant$ <he recipient and the donor tissue must be closely matched prior to har"esting and necessary procedure and treatment are conducted prior to har"esting to pre"ent the ris% of infection and other complications$
/iologic Thera+y& ;nterferon and interleu%in 8cyto%ines9 may be used to treat leu%emias$

<hey modify the body's response to cancer cells, moderate immune function and inhibit abnormal cell proliferation and gro!th$ :pon admission of the client, he !as gi"en @aracetamol for his fe"er, ;1 <e=ocin 6$>g tds for his antibiotic and ;1 infusion of 2 pints normal saline in 26 hours$ He !as also gi"en a series of blood transfusion due to lo! haemoglobin countA ho!e"er, any of the abo"e treatment options !ere not gi"en to the patient$

Ta(le 3& Schedule of /lood Transfusion

Date 07$1$2011 0,$1$2011 10$1$2011 11$1$2011

Ta(le 4& Medication

Time 7 *0 pm 7 60 pm 7 20 pm 7 00 pm

Amount Transfused $ml% *>0 *>0 *6> **1

)eaction 4o 4o 4o 4o

0ame

Indications

Side Effects

Case Study on Acute Lymphocytic Leukemia

;1 <a=ocin 6$>mg <reatment of systemic and local 8<329 bacterial infection in susceptible organisms$ 7o!er the respiratory tract infection$

3iarrhoea, rashes, nausea, "omiting, increased s!eating, !ea%ness, dry mouth, muscle pain$

<$ @aracetamol 1g Analgesic$ /elief of pain and fe"er 1omiting, nausea, 8@/49 in adult and children$ abdominal pain, anuria, li"er in#ury, oedema

<he physician of Mohammed order treatment of chemotherapy and bone marro! aspiration, but the patient and his parents refused for the said treatments e"en after the physician's e(planations about his illness, its complications e$g$, bleeding, infection, coma and death, if remain untreated and poor prognosis if treatment is delayed$ <he patient's mother only preferred symptomatic treatment and follo! up$

Possi(le Com+lications
.omplications of leu%emia and its therapy may differ from one patient to another$ <he follo!ing are the possible complications
Tumor

ysis Syndrome5 /apid destruction of large numbers of malignant cells leads to alteration in electrolytes (hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia)#

Se+sis5 3ue to lo! immunity )enal Failure5 3ecreased urine output and increased blood urea nitrogen and creatinine$ /leeding $su(arachnoid6 renal haemorrhage%: 3ue to thrombocytopenia 8lo! platelet

count9 leads to bruising, petechiae, bleeding gums, and bleeding !ithin specific organs and tissues$
0euro+athy5 ;nfiltration of leu%emic cell in the .42 Sei7ure 8also called conv lsion9 3ue to increased intracranial pressure$ 2ei=ure is a

single e"ent abnormal electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function
Disseminated Intra1ascular Coagulation $DIC%5 A disruption of haemostasis

characteristic by !idespread intra"ascular clotting and bleeding

eu*ostasis5 &lood "essel !alls are infiltrated and !ea%ened, !ith high ris% of rupture and bleeding, including intracranial haemorrhage

:ntil Mohammad !as discharge, no complications ha"e been reported$

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

Discharge Plan
Mohammed !as discharge on 12 January 2011$ He !as alert, conscious but the s%in !as a bit pale$ His blood pressure !as 1*6+F0 mmHg, pulse of 116 bpm, respiratory rate of 20 breath per minute and s@)2 of 100E$ He !as afebrile and no more complaint of bone pain and his blood test sho!ed still on the lo! side$ :pon his discharge, his physician and staff nurses ad"ised him and his mother on ho! to %eep him healthy as possible, ho! to pre"ent himself from getting in#ury, infection, and !hat to do if signs and symptoms of illness !ill come bac% again$ A& Follo,2u+ Care He !as ad"ised to come to leu%emia clinic in 1 month time for blood test$ He !as ad"ised for a regular chec%5up, necessary to help ensure that any changes in his health are noted and treated if needed$ ;f any health problems bet!een chec%5ups are encountered, contact his doctor immediately or come to the hospital$ .hec%5up may include a careful physical e(amination, blood tests, cytogenetic, (5rays, bone marro! aspiration, or spinal tap, only upon consent is gi"en$ /& Self Hel+ .uide At Home
Diet5 Gat a "ariety of healthy foods from all the food groups e$g$, breads, "egetables,

fruits, mil% and mil% products, and protein 8beans, eggs, poultry, meat and fish9$ Gating healthy foods may help you feel better and ha"e more energy$ Hou may need to ma%e diet changes depending on your tolerance$ Gat small5fre0uent meal and snac%s rather than 1 big meal !hich !ill only suppress the appetite$

Case Study on Acute Lymphocytic Leukemia

 Drin* Fluids5 3rin% about about 25* liters of li0uid each day or prescribed by doctor$

.hoose healthy li%e !ater, #uices, and mil% rather than carbonated drin%s$ ;f you are used to drin%ing li0uids that contain caffeine, such as coffee, these can also be counted in your daily li0uid amount$
A1oid Consti+ation5 <ry to %eep from getting constipation or diarrhoea$ <hese can

irritate the rectum !hich can cause infection$ 3o not try to push the stool out if it is too hard$ Dal%ing is the best !ay to %eep your bo!els mo"ing$ Gat food high in fiber e$g$ cereals, beans, and !hole grain breads$ :se fiber medicine or a stool softener as prescribed by doctors to soften stools and easy e(cretion$
)est5 &alance acti"ity to the amount of energy you ha"e$ 4ap a couple of times

during the day$ Going to bed early and getting up late may also help$
Exercise5 G(ercise %eeps you healthy$ 3ecrease acti"ities if blood cell count is lo!

based on the result of blood test$ As% your doctor to help you plan the best e(ercise program for you$ 2tart e(ercising !hen your doctor says it is )I$ ;t is best to start slo!ly and do more as you get stronger$
A1oid Things That Can Cause Cuts "r /ruises5 3o not play contact sports since it

may bleed or bruise easily$ A& Pre1enting Infection

Hand ,ashing& Dash hands after using the bathroom and before eating !ith correct

hand !ashing techni0ue$

Sho,er daily& Ieep yourself clean daily to pre"ent accumulation of microorganisms

on your s%in$
Use a deodorant s+ray instead of anti+ers+irant& Antiperspirants bloc% s!eat

glands !hich can cause an infection$

/rush teeth t,o to three times a day& :se soft5bristle toothbrush and gently brush

teeth to a"oid bleeding and infection$ 2ee your dentist for regular chec%5ups to detect and treat dental infection and diseases$
Do not ,ater and ta*e care +lants and flo,ers& Microorganisms are present in

plant dirts and flo!er "ase !ater$

Perineum care& .lean perineum area properly each time you pass urine and bo!el$ Stay a,ay from colds or flu&

2tay a!ay from large groups of people this !ill decrease chances of getting sic% e$g$ colds and flu$

.et 1accinated& Get shots of "accination to %eep from getting flu and pneumonia$ A. A1oid /ruises and /leeding /e,are of (um+s and cuts& 3o not play contact sports such as football or soccer$ /e,are of high altitudes& 3o not do any acti"ity that may cause chest pain or

trouble breathing$

Case Study on Acute Lymphocytic Leukemia

 /e,are of sli++ery sli++ers and shoes& Dear non5s%id slippers or shoes !hen are

out of bed and !hen !al%ing outside especially slippery and !et floors and grounds$ <his !ill %eep you a!ay from slipping or falling$
/e,are of hard2(ristled tooth (rush& :se soft5bristled brush to help pre"ent gum

bleeding$ 3o not floss teeth !hile platelet count is lo!$ 3o not use tooth pic%s, it may pric% your gums$
Do not (lo, your nose hard& ;t may damage of the mucous membrane increasing

the ris% of bleeding$

Use nail cli++ers or a nail file& 3o not use scissors to trim your nails$ :se nail file to

smoothened the nails and trim the sides$

A1oid straining during (o,el mo1ement& As% the doctor for stool softeners to

pre"ent constipation$ Dal%ing helps to %eep bo!els mo"ing$

/e,are of As+irin& 3o not ta%e medicine containing aspirin$ Aspirin is for thinning

of the blood increasing the ris% of bleeding$

Put +ressure on the (leeding area& ;ce pac%s cool the area and decrease blood flo!$

@ut the ice in a plastic bag and co"er !ith to!el and place o"er at the in#ured area$
A. See* care immediately if the follo,ing is ex+erienced5 .hest pain$ <rouble breathing$

?e"er for the last 2 !ee%s

2igns of minor bleeding, such as petechiae, ecchymosis, con#uncti"al haemorrhage,

nose bleed, bleeding gums, bleeding at puncture sites$

&e alert for signs of serious bleeding, such as headache !ith change in

responsi"eness, blurred "ision, haemoptysis 8coughing op of blood9, hematemesis 8"omiting of blood9, melena, hypotension, tachycardia, di==iness$

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

Case Study on Acute Lymphocytic Leukemia

/i(liogra+hy
Cancer$ 8200,, ?ebruary 229$ /etrie"ed January 1>, 2011, from <he @atric% 3emsey .enter for .ancer Hope and Healing http ++dempseycenteratcmmc$com+cancers+"ie!s+.3/2>7F,F .eukemia$ 8200F, June 269$ /etrie"ed January 1>, 2011, from Medicine4et$com http ++!!!$medicinenet$com+leu%emia+article$htm (cute .ymphocytic .eukemia$ 82010, ?ebruary F9$ /etrie"ed January 16, 2011, from <he 7eu%emia and 7ymphoma 2ociety http ++!!!$leu%emia5lymphoma$org+allJpageK itemJidL706F .eukemia$ 82011, January 69$ /etrie"ed January 1>, 2011, from Di%ipedia <he ?ree Gncyclopedia http ++en$!i%ipedia$org+!i%i+7eu%emiaMacute lymphoblastic &ur%e, @$ 7$ 8200,9$ /edical +urgical 9ursing 86th ed$9$ 4e! Jersey, :2A @earson Gducation ;nternational$ 7hynnelli$ 8200F, April >9$ .eukemia Case +tudy$ /etrie"ed January 16, 2011, from 4ursing .rib$com http ++nursingcrib$com+case5study+leu%emia5case5study+ 4ori%o 2ata%e, M$ 82010, April 69$ (cute .ymphoblastic .eukemia$ /etrie"ed January 1>, 2011, from DebM3 http ++emedicine$medscape$com+article+FF011*5o"er"ie!

Case Study on Acute Lymphocytic Leukemia