Blood & Lymphoreticular System

{"ops":[{"insert":"Diagnosis and reasoning"},{"insert":"\n","attributes":{"header":1}},{"insert":"This elderly lady has presented with a 3 week history of melena; this is an extremely concerning presentation which raises the spectre of upper gastrointestinal (GI) bleeding. Note that the presence of pallor lends further credence to this possibility.\n\nHer examination reveals another disconcerting finding: massive splenomegaly (i.e. a spleen which extends 8 cm or more beyond the costal margin). This sign is caused by only a few conditions; of these, it is only myelofibrosis and chronic myeloid leukemia (CML) which are likely to present in this manner.\n\nNote also that she is icteric; this might be due to involvement of the liver in the disease process; alternately, it might be due to hemolysis secondary to hypersplenism.\n\nFortunately, her vital parameters are stable; nevertheless, large bore intravenous access should be established, and patency maintained via a fluid drip.\n\nAn urgent upper GI endoscopy should be the next step, aiming to identify the source of bleeding; this reveals gra"}]}

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