June 2016 A 49-year old male presents with headache, fatigue, and pain under his left ribs PMH includes depression and newly diagnosed hypertension Physical Exam: BP, 160/90; Abdominal exam reveals splenomegaly spleen palpable 6 cm below costal margin Laboratory values: Hb=20.7 g/L HCT= 59.4% WBC=10.2x109/L Platelets= 325 x109/L Bone marrow biopsy: MF-1 fibrosis and megakaryocytic hyperplasia with atypia JAK2-positive Patient was started on phlebotomy as needed and aspirin 81 mg October 2016 Patient returns 4 months later with continued headache and dizziness He has had 3 phlebotomies in the past 3 months Patient was started on hydroxyurea 1000 mg/day January 2017 Patient returns 3 months later with abdominal fullness, continued fatigue, difficulty concentrating, fever, and leg ulcer Laboratory values: Hb= 22.4 g/L HCT= 65.3% WBC=13.3x109/L Platelets=153x109/L Patient is started on ruxolitinib