Health Overview

• Patient: Ishamma T M (DOB 1944-07-01, Female, age ~81)
• Family/Caretakers: Sameer Badarudeen (son, remote coordinator), Nisha (bedside caretaker)
• Primary Diagnosis: Acute Myeloid Leukemia with MDS-related gene mutations (adverse-risk; RUNX1, ASXL1, BCOR, SRSF2, STAG2, NRAS; karyotype 46,XX normal)
• Treatment: Azacitidine (IV) + Venetoclax (Cycle 1 started 2025-12-09/10; port placed Dec 9). Supportive: Acyclovir (antiviral), Posaconazole (antifungal; CYP3A4 inhibitor enabling VEN dose reduction)
• Last chemo cycle: 2026-04-06 to 2026-04-13 (Cycle 4+; AZA 5 days IV + VEN 5 days)
• Schedule evolution: AZA 5 days since at least Cycle 2 (Jan 19). VEN: 10 days (Cycle 2) → 5 days (Cycle 4+)
• Pegfilgrastim (G-CSF): Discontinued 2026-03-30 due to significant bone pain
• Cycle 5: Not yet scheduled/documented. Estimated window May 4–17 based on C4 Day 1 (Apr 6).
• Status (May 4–6): Multi-lineage hematopoietic recovery. All electrolytes normalized. Pancytopenia resolved. Hyponatremia resolved. Hb approaching normal threshold (11.9 of 12.0). 13 active medications; 4 confirmed non-adherent.
• Status (May 27): LANDMARK Hb 12.0 (first normal since AML Dx). Active Aza-Ven cyclical nadir: WBC 2400 (L), ANC 1460 (L — moderate neutropenia). Plt stabilizing 107K (thrombocytopenic). Electrolytes normal.
• Status (June 1): SEVERE NEUTROPENIA: ANC 990 (Grade 3, <1000) — deepest nadir since stabilization. CRITICALLY ELEVATED infection risk. Platelets fully recovered to 252K (normal). Hb dropped to 11.3 (anemic). MCV 100 fL (highest on record, worsening macrocytosis). See Current Clinical Picture.

Current Clinical Picture (as of 2026-06-01)

Hematologic — SEVERE NEUTROPENIA NADIR (Cycle 5 cyclical myelosuppression)

[!danger] SEVERE NEUTROPENIA — ANC 990 (Grade 3, CRITICAL, June 1)
ANC has dropped to 990 cells/cumm — SEVERE NEUTROPENIA (CTCAE Grade 3, <1000 threshold). This is the deepest ANC nadir since March 2026 stabilization, approaching the February 2026 crisis levels (610-880 range). WBC also at deepest nadir: 2200 cells/cumm. Polymorphs only 46% (lowest on record), with relative lymphocytosis 42.8%.

CRITICALLY ELEVATED infection risk. Life-threatening bacterial/fungal infection risk. Acyclovir + posaconazole prophylaxis ESSENTIAL. Monitor for:
- Fever (>38°C / 100.4°F) — requires urgent evaluation
- Mucositis, oral ulcers
- Skin infections
- Respiratory symptoms (pneumonia risk)
- Avoid crowds, sick contacts, uncooked food

Expected recovery: Based on prior cycle patterns, ANC should begin rising within 3-7 days (~June 4-8). Repeat CBC in 2-3 days to confirm turnaround. No G-CSF available (pegfilgrastim discontinued). See Anc, Wbc.

[!success] PLATELETS FULLY RECOVERED — 252K (Normal, June 1)
Platelets have fully recovered to 252K (+145K from May 27) — well within normal range (150-400K). Bleeding risk resolved. Confirms classic lineage dissociation: platelets recover ~10-14 days before granulocytes. Platelet recovery signals ANC recovery should follow within days. See Platelet Count.

Hb dropped from landmark normal 12.0 (May 27) to 11.3 g/dL (−0.7 g/dL), returning to anemic range. Possible mechanisms: hemodilution (MCV increased to 100 fL), ongoing erythroid suppression, or dissociated lineage kinetics (erythroid lagging granulocyte recovery). RBC also dropped to 3.53 (from 3.77). See Hemoglobin, Rbc Count.

MCV jumped to 100 fL — the highest MCV recorded at KIMS, exceeding prior DDRC peak of 99.8 fL. This is +5.0 fL from May 27 (95 fL). Possible causes: azacitidine cumulative effect, stress erythropoiesis, functional folate/B12 deficiency, or hemodilution. RDW 18.3% (persistent anisocytosis). See Mcv, Rdw.

Metabolic / Electrolytes — NORMALIZED

[!success] Full electrolyte normalization (May 4)
Na 128→134→142 (N), Mg 1.2→1.4→1.6 (N), Cl 93→95→103 (N). Hyponatremia — RESOLVED (date 2026-05-04, after ~97 days). Oral Mg supplement 400 mg TID confirmed active (2026-05-06). See Hyponatremia, Sodium, Magnesium.

Glycemic (Diabetic Context)

• HbA1c: 5.7% (Mar 2026) — unreliable; spuriously low due to altered RBC turnover in AML
• Fructosamine: 310 µmol/L (HIGH, ref 122–236; Apr 22, 2026) — preferred glycemic marker in AML; reveals poor short-term glucose control
• Active DM meds: Insulin degludec 10U q.d., linagliptin 5 mg q.d., metformin 500 mg TID
• NOT being taken (confirmed 2026-05-06): Insulin glargine (non-adherent)

Fructosamine 310 µmol/L reflects ~1–2 weeks of hyperglycemia despite three active DM agents. HbA1c improvement is spurious. Home glucose monitoring not documented. Repeat fructosamine due ~May 20–27. See Fructosamine, Diabetes Mellitus.

Renal/Hepatic

• Creatinine: 0.6 mg/dL (Apr 6, N; 5 data points, range 0.62–0.9, all normal). Stable renal function through 4+ cycles of Aza-Ven.
• BUN: 13.4 mg/dL (Apr 6, N). See Urea.
• LFTs: TBil 0.2, ALT 11, AST 15, ALP 63, TP 7.3, Alb 4.4 (Apr 6 — most recent). All normal. Verified × 3 panels (Jan, Mar, Apr 2026). No hepatotoxicity after 4+ months of azacitidine + venetoclax + posaconazole. See Lft.
• Calcium: 9.9 mg/dL (Mar 2, N). Transient hypercalcemia Jan 19 (10.7) → self-resolved Jan 22 (10.1). See Calcium.

Treatment Response Summary

Active Concerns (as of 2026-06-01)

1. SEVERE NEUTROPENIA (June 1) — ANC 990, WBC 2200 — CRITICAL — Grade 3 severe neutropenia (<1000). Deepest nadir since March 2026 stabilization. CRITICALLY ELEVATED infection risk — life-threatening bacterial/fungal infection risk. Acyclovir + posaconazole prophylaxis ESSENTIAL. Fever >38°C requires urgent evaluation. Monitor for mucositis, skin infections, respiratory symptoms. Avoid crowds, sick contacts, uncooked food. Expected recovery: ANC should begin rising within 3-7 days (~June 4-8) based on platelet recovery trajectory (Plt now 252K, fully normal). Repeat CBC in 2-3 days. No G-CSF available (pegfilgrastim discontinued). This is the most critical infection risk period of current treatment cycle. See Anc, Wbc, Aml.
2. True diabetes with poor glycemic control — Fructosamine 310 µmol/L (HIGH). HbA1c unreliable. Three DM agents active; insulin glargine not being taken. Repeat fructosamine due ~May 20–27. See Fructosamine, Diabetes Mellitus.
3. Diabetic neuropathy (presumed) — underdosed, no formal Dx — Pregabalin 75 mg q.d. is below MED (≥150 mg/day divided). No neuropathic symptom documentation, no NRS score. DPN not formally diagnosed. Duloxetine preferred add-on (FDA-approved, no CYP3A4 issue with posaconazole); pre-initiation: GFR recheck, Na recheck, LFTs (all last Apr 6 — due repeat). See Duloxetine Vs Mirtazapine Diabetic Neuropathy.
4. Pregabalin fall risk — Age 81. CNS side effects (dizziness, ataxia, somnolence). No falls risk assessment or TUG documented. See Pregabalin.
5. No statin currently active — Atorvastatin not being taken; posaconazole CYP3A4 interaction resolves safety concern for non-CYP3A4 statins (pravastatin, rosuvastatin). Cardiovascular risk in T2DM and age >75 warrants evaluation. See Atorvastatin.
6. No BP documented — On losartan 50 mg monotherapy (HTN presumed by prescription). No BP readings in vault. See Hypertension.
7. Cycle 5 not yet scheduled — Last documented: Cycle 4 Day 1 Apr 6. ANC 2360 on May 4 is favorable for cycle initiation. No appointment record in vault.
8. Hypomagnesemia resolved but at lower limit — Mg 1.6 (lower bound of 1.60–2.60). Supplementation (400 mg TID) should continue. Target mid-range (≥2.0 mg/dL). See Magnesium, Magnesium Oral.
9. SIADH workup never completed — Na now normalized; etiology of Jan–Apr 2026 hyponatremia remains unconfirmed (urine osm, urine Na never drawn). Hyponatremia predates AML (Na 132 in Nov 2022). Workup warranted if recurrence. See Hyponatremia.
10. Transfusion reaction history — Sudden chills and breathing difficulty during transfusion on 2025-12-10. Future transfusions require pre-medication. See Allergy List.
11. No MRD monitoring — Critical gap given adverse-risk molecular profile (RUNX1, ASXL1, SRSF2). No post-Cycle 3 BMBx or flow cytometry documented. See Mrd Targets Explained.
12. Adverse-risk molecular profile — RUNX1, ASXL1, BCOR, SRSF2, STAG2, NRAS. Long-term prognosis guarded without SCT (patient ineligible by age/fitness). See Aml.

Active Medications (13 total — 2026-05-06)

Confirmed NOT being taken (as of 2026-05-06): nifedipine, atorvastatin, insulin glargine, prednisolone.
Polypharmacy alert: 13 active medications; 81-year-old patient; adherence confirmation for remaining 9 medications warranted.

Active Providers

• Bijay Prabhakaran Nair — Oncologist, KIMS Health (primary AML treating physician)
• Ashwin V Nair — Hematology/Oncology, KIMS Health

Conditions Status Summary

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