Patient A probably has many more enlarged abdominal nodes that cannot be felt by mere physical exam, but given his bulky lymphadenopathy (big word that means swollen nodes or glands) and swollen spleen (“splenomegaly”), chances are good a CT scan will find a lot more enlarged lymph node clusters in his abdomen. The 30K ALC in his blood test is nothing . It is a mere tip of the iceberg, as much as 90% or more of his disease burden (total number of CLL cells in the body) are in those swollen lymph nodes, spleen, may be liver and bone marrow, beyond the reach of a mere blood test.
It is also important to distinguish blasts from large reactive lymphocytes, which can really mimic each other. Again, we use various findings, including clinical signs, hematologic results, cytologic features of the cells, to help make this determination (. everything is context- or case-dependent). In some cases, we cannot distinguish between “blasts” and reactive lymphocytes. In such cases, evaluation of the patient for evidence of cancer or serial monitoring of the patient will be needed to help with this distinction.
Adrenal insufficiency: These patients will present with abdominal pain, nausea/vomiting, diarrhea, weakness, fatigue, salt craving, and often hypotension. Blood pressure may be resistant to vasopressors. Ask the patient about prior steroid courses and known adrenal insufficiency. Evaluate for risk factors such as tuberculosis, chronic steroid use, and metastatic cancer. Risk factors from the history and laboratory findings such as hyponatremia, hyperkalemia, hypoglycemia, and hypercalcemia can assist in the diagnosis (primarily in primary insufficiency). Hydrocortisone in stress doses (100mgIV X1) is required if this is diagnosed. 11