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+--- Thread: Very easy and V practical Q - dolly123 (/showthread.php?tid=295795)
Very easy and V practical Q - dolly123 - ArchivalUser - 04-24-2008
A 68-year-old man presents to hospital with complaints of worsening fatigue for the past few weeks. Two months ago, his nephrologist started him on erythropoietin after dialysis. He has been on hemodialysis for the past 19 years because his type II diabetes was never controlled. He denies chest pain or dizziness but reports feeling "awfully winded after I walk for one block." He also denies melena, hematochezia, or other bleeding. His medications include insulin, phosphate binders, and amlodipine. On physical examination, he appears pale and tired. His temperature is 98.9 F, and respirations are 18/min. When seated, his blood pressure is 140/72 mm Hg, and his pulse is 96/min. When standing, his blood pressure becomes 148/80, and pulse becomes 98/min. Heart and lung sounds are normal, and his abdomen is benign. Rectal examination reveals a trace guaiac-positive stool. Laboratory studies show:
CBC: WBC 8,000/mm3; hemoglobin 9.5 mg/dL; hematocrit 31%; platelets 320,000/mm3.
MCV 72 FL (normal 82-98 FL); MCHC 30 g/dL (normal 32-36 g/dL); RDW 17% (normal 13-15 %)
Reticulocyte count (corrected) 1%
Serum iron: decreased
Ferritin 12 ng/mL (normal 15-200 ng/mL); TIBC elevated
Bilirubin 0.4 mg/dL; direct bilirubin 0.2 mg/dL
EKG: no new ST-T wave abnormalities, no Q waves
Chest x-ray: borderline cardiomegaly
What is the next best step in the management of this patient?
(A) Ferrous sulfate
(B) Blood transfusion
© Colonoscopy
(D) Increase the erythropoietin dose
(E) Bone marrow biopsy
0 - ArchivalUser - 04-24-2008
Elderly with microcytic anemia.
C. Colonoscopy
virtuoso
0 - ArchivalUser - 04-24-2008
ans C.
hav to confirm the diagnosis
0 - ArchivalUser - 04-24-2008
© Colonoscopy
Tricky one
0 - ArchivalUser - 04-24-2008
Posted this cuz saw it many times in a nephro rotation i did, things u see on the wards seem so relevant when u read a case about it!
© Colonoscopy
Explanation:
This patient has an anemia of chronic disease from renal failure as well as iron deficiency. There is a deficiency of erythropoietin secretion because of renal failure, which usually causes a normocytic anemia with a decreased reticulocyte count. The other cell lines should be unaffected. Despite being on erythropoietin for two months, he is not symptomatically better, and his laboratory tests suggest an iron deficiency. His cells are microcytic, the ferritin is low, and the total iron-binding capacity (TIBC) is elevated. If this were just anemia form renal insufficiency, he would have a high ferritin level and a low TIBC. Increasing the erythropoietin alone will have no effect on the blood count.
The most common cause of iron deficiency is blood loss. In a man above the age of 50, gastrointestinal blood loss is certainly the most common cause. Beside the anemia, being older than 50 requires that he get a colonoscopy once every ten years to screen for colon cancer. He is hemodynamically stable with no orthostatic changes, no chest pain, and no EKG changes, and the hematocrit is above 30%; therefore, transfusion at this time is not indicated. Although we would be treating his iron deficiency with ferrous sulfate, the more important underlying cause would be ignored. Although a bone marrow biopsy is the most sensitive method of detecting an iron-deficiency anemia, it is not necessary in this case