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1.easy fatiguability - increase susceptibility to fatigue - lethargy
2. gingival - tissue of upper or lower jaw - gum - found in oral cavity

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Key information
1.20-year-old male : immunocompetent ; male - lower innate and adaptive  immune response - female have x chromosome ; high testosterone- immune suppressant

2.gingival  bleeding  of  one  day  duration-build up of plaque at gum line, thrombocytopenia, haemophilia, scruvy, coagulation factor deficiency

3.easy fatiguability,headaches - leukemia, anemia,CNS problem (meningitis), infection

-few episodes of nose bleed - blood vessel injury of lining of nose, acute sinusitis, infection, exposed to chemical, cancer, leukemia

4.no  significant  past  medical  or  surgical  history - immunocompetent

5. neither smokes nor drinks alcohol - unlikely cancer cause by smoking/alcohol

6. not taking any regular medication - no taking anticoagulant - symptom not cause by taking drug

7.No  history  of  allergy  to  drugs - no reaction to drug

8.Family  and  social  history were unremarkable -unlikely to be inherited disease

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Differential diagnosis
1. Scruvy - gum bleeding, headache
2.Infection (bacterial/viral)
3.Leukemia
4. Anemia
5. acquired coagulation disorder (DIC, vit. K dependent factor deficiency)
6. Haemophila
7. TTP (thrombotic thrompocytopenia purpura)

Further questioning
1. physical examination - vital sign
2. FBC
3. BM examination
4. Coagulation test
5. FBP

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1. multiple ecchymotic skin lesion- bruises on the skin due to continuous - appear blue black
2. lower extremeties- body part that includes leg and ankle, feet
3. D- dimer - fragment that make when the blood clot dissolve in the body
4. auer rods- pink or red stain that we obseve in the myeloid cell - due to aggregation of myeloperoxidase that contain in myeloid cell
5. marrow aspiration - sample of fluid from BM - check for specific cell - asess cellularity , fragment stores and iron stores
5. faggot cell - blast with multiple auer rods in the cytoplasm - hallmark for AML
6. sinus rhythm- rhythm of healthy human heart
7.

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1. pale  with  multiple ecchymotic skin lesion measuring from 2 to 3 cm in diameter on lower extremeties- physical trauma- pale due to anemia- AML can cause this due to bleeding in the skin-insufficient thrombocytes - thin blood vessels easily ruptures- high pressure during walking or running

2. lungs  were  clear  and  no  organomegaly found  on  abdominal  examination- no abscess- no edema- no cavitation - no infection -

3. no  evidence  of regional lymphadenopathy.- no abnormality in the lymph node- if lymph node swollen indicates infection

4. presence  of  abnormal  mononuclear  showing  Auer rods in the cytoplasm with few typical Faggot cells-shows promyelocyte- hallmark for APL

5. consistent  with  the  diagnosis  of  acute  myeloid  leukaemia

(AML).- presence of faggot cell and showing auer rods indicated this disease

6. bleeding manifestations associated with

abnormal  blood  coagulation  tests  accompanied  by
progressive thrombocytopenia-due to low platelet - progressive and severe - tendency to bleed higher- bleeding cause reduction in platelet
decreasing  fibrinogen,- causes defect in the secondary hemostasis - coagulation factor decrease and not activate - VWF decrease
elevated  D-Dimer levels- indicates the patient has DIC

7. laboratory evidence of disseminated intravascular coagulation (DIC)- significant problem that occurs in AML- could be due to APL as well

8. vital signs- temp and bp normal -pulse rate high (tachycardia) - need more o2

9. Hb low due to bleeding , Hematocrit low due to low RBC , MCV, MCH , MCHC normal- normochromic normocytic , rdw normal, total white cell count normal,

10. WBC- neutrophill low, lymphocytes low, monocytes normal, eosinophill normal- basophill normal -  impaired hemotopoiesis due to AML-

11. CRP high due to inflammation - higher risk of MI - respond to injury and infection -

12.   prothrombin time long - due to DIC

13. INR high - measures the time for clot
14. plasma fibrinogen low due to

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Differential diagnosis
1. Scruvy - gum bleeding, headache
2.Infection (bacterial/viral)
3.Leukemia-AML /APL  DIC
4. Anemia
5. acquired coagulation disorder (DIC, vit. K dependent factor deficiency)
6. Haemophila
7. TTP (thrombotic thrompocytopenia purpura)

FURTHER QUESTIONING
1. IMMUNOPHENOTYPING
2. chromosomal study
3. DNA STUDY using PCR

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1.FISH- method to study translocation in DNA
2. complete remission- disappearance of cancer sign due treatment
3. chromosomal  translocation- chromosome break and either whole or portion of it reattach to another chromosome
4. immunophenotyping- technique that use Ab to identify cell based on Ag type or marker on surface cell
5. flow cytometry - recognize pattern and intensity of different Ag on surface normal and leukaemic cell

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1. prompt treatment of the DIC related bleeding with blood component

therapy initiated - o specific treatment and use only blood transfusion

2. normalisation of the blood coagulation tests - indicate DIC

Treatment with specific combination

chemotherapy retinoic acid (ATRA),

idarubicin,

and

arsenic

trioxide)

along

with

supportive

care

were

started.

He

achieved complete remission and

had a favorable response.

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acute myleoid leukamia with DIC