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A 46-year-old woman with alcoholism is evaluated because of a 4-day history of nausea and vomiting after a recent binge. She has diffuse epigastric pain. She has been hospitalized intermittently for years for medical complications related to alcohol abuse, including cirrhosis with ascites and bleeding esophageal varices. On physical examination, her temperature is 37.3 °C (99.1 °F), pulse rate is 68/min, and blood pressure is 135/70 mm Hg. She has jaundice and is icteric. Her lungs are clear to auscultation. The remainder of her physical examination is unremarkable.
Laboratory studies:
Hemoglobin 7.1 g/dL
Leukocyte count 4500/μL
Platelet count 115,000/μL
Mean corpuscular volume 107 fL
Reticulocyte count 5.4%
Serum alkaline phosphatase 592 U/L
Serum aspartate aminotransferase 198 U/L
Serum alanine aminotransferase 166 U/L
Serum total bilirubin 9.2 mg/dL
Serum indirect bilirubin6.4 mg/dL
Serum albumin 2.2 g/dL
Serum folate 12 ng/mL
Which of the following diagnoses best explains the findings?
A. Spur cell anemia
B. Folic acid deficiency
C. Hypersplenism
D. Acanthocytosis
4
A 62-year-old man is evaluated because of increasing fatigability. He previously felt fine. He has recently been found to have osteomyelitis underlying a diabetic foot ulcer and is being treated with ciprofloxacin and amoxicillin/clavulanate.

Laboratory studies:
Hemoglobin 9.8 g/dL
Mean corpuscular volume 79 fL
Serum creatinine0.9 mg/dL
Serum iron 38 μg/dL
Serum total iron-binding capacity 190 μg/dL
Serum ferritin 298 ng/mL
Which of the following constitutes appropriate additional therapy?
A. Cyanocobalamin
B. Ferrous sulfate
C. Parenteral iron
D. Recombinant human erythropoietin and ferrous sulfate

for Q1 i think C. might be suitable
something that damaged RBC and bone marrow continue to produce new
RBCs due to a high reticulocyte count
Q2 i have no idea

c
d?

C....
B?

_ Q1: CCC

_ Q2: DDD > AA

bbbb
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ohho ddd for 2nd one shit sleepy gn

1a
The patient has spur cell anemia. In a small percentage of patients with alcoholic cirrhosis, erythrocytes accumulate large amounts of free cholesterol with significant erythrocyte membrane distortion. A progressive severe hemolytic anemia ensues, with cells that partly resemble acanthocytes.
Unlike true acanthocytes, the cells in spur cell anemia are small and spheroidal with short, spiny projections (hence the term spur cell). Increased amounts of membrane cholesterol lead to increased membrane surface area. Membrane distortion forms the basis of the morphologic presentation secondary to abetalipoproteinemia. The spur cells are trapped and destroyed in the splenic cords leading to progressive splenic enlargement.
The prognosis of patients with spur cell anemia is extremely poor. Splenectomy is occasionally effective in moderating the hemolysis, but patients usually have underlying portal hypertension and coagulopathies, which complicate the procedure.
More often, patients with alcoholic liver disease may have chronic, mild to moderate anemia that is multifactorial (liver disease, hypersplenism, alcohol as a direct toxin to erythroid progenitor cells). Liver disease, particularly extrahepatic biliary obstruction, may be associated with membrane changes such as target cell formation. With an increase in cholesterol, the cholesterol : phospholipid ratio changes, and the cell membrane surface area increases. Thus, the cells become broad and flat. As the cells dry, hemoglobin collects in the thicker areas of the cells (the center and edges) producing a œtarget™ appearance.
Folic acid deficiency should be considered in any patient with alcoholism who has a macrocytic anemia. In this patient, however, the high reticulocyte count makes this diagnosis unlikely. The patient probably has preexisting hypersplenism, based on her diagnosis of cirrhosis, but it would not account for her severe anemia and elevated reticulocyte count. Patients who have chronic alcoholism should be maintained prophylactically on folic acid supplementation.

2d
The patient has anemia of chronic disease, for which erythropoietin (usually given concurrently with iron) is an effective therapy. His serum iron and total iron-binding capacity are low, but his reticuloendothelial iron stores are adequate, as demonstrated by his elevated serum ferritin level. The clinical picture is characteristic of anemia of chronic disease, which often includes mild microcytosis.
If the patient were asymptomatic, it would be appropriate to focus treatment on the osteomyelitis alone. Because the anemia is associated with symptoms, specific therapy for anemia is indicated. Iron therapy by itself is not effective in anemia of chronic disease. Cyanocobalamin is a treatment for vitamin B12 deficiency but not for anemia of chronic disease.

_ Thanks showman, for the qs. and full explanation.