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Online Cases 3-29-11 Tues 2

Online Cases 3-29-11 Tues 2 - Online Cases Anemia and...

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Online Cases 3-29-11 Anemia and Thrombocytopenia I. HISTORY PATIENT PRESENTATION A 32-year-old African-American woman comes to the ER complaining of episodic orbital headaches, difficulty moving her tongue, difficulty speaking, and intermittent numbness of extremities for the last week. A CBC was ordered as part of initial workup. Upon receiving the results, the ER physician calls you. You review the CBC results: Patient Result Normal Value WBC (x10 3 /mm 3 ) 7.1 Neutrophils 88% Bands 3% Lymphocytes 5% Monocytes 4% 4.8-10 Hemoglobin (g/dL) 7.4 12-16 Hematocrit (%) 24 37-47 RBC (x10 6 /mm 3 ) 2.9 4.2-5.4 MCV (fL) 86 78-96 RDW 21.3 - Platelet Count (x10 3 /mm 3 ) 38 180-400 According to the CBC, what hematologic problems are present? Anemia Good choice! COMMENT: The patient’s low red blood cell count, low hemoglobin level, and low hematocrit level indicate anemia. To review the pathophysiology of anemia, click here . Neutrophilia Incorrect. COMMENT: Although the patient has an increase in neutrophils on the differential, the total WBC and absolute neutrophil count are normal. Pancytopenia Incorrect. COMMENT: The patient has anemia and thrombocytopenia (reduction in two cell lines), but has a normal WBC. Pancytopenia is a reduction in all three cell lines. Thrombocytopenia
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Good choice! COMMENT: The patient’s low platelet count is an indicator of thrombocytopenia. To review the pathophysiology of thrombocytopenia, click here . What additional questions would you ask the patient at this time? Do you drink any alcohol? Good choice! PATIENT RESPONSE: One beer during the week prior to admission. COMMENT: This question is relevant because ethanol can cause decreased marrow production of red blood cells (because of concomitant folate deficiency) or platelets due to a toxic effect on megakaryocytes in the bone marrow. Have you ever been told that you were anemic? Good choice! PATIENT RESPONSE: The patient states that she has been told about anemia for 15-16 years, but her physician thought it was secondary to increased menstrual bleeding due to fibroids. She says that she was treated successfully with iron. COMMENT: This question is relevant because it is essential to determine if anemia is acute or chronic in order to determine the most likely etiology. Have you had any bruises or bleeding? Good choice! PATIENT RESPONSE: No. COMMENT: This question is relevant because it may help you to determine the onset of her thrombocytopenia. Did you eat any fava beans yesterday? Incorrect! COMMENT: Fava beans precipitate severe hemolytic anemia in patients with G6PD deficiency. However, it is a sex-linked disorder that is, therefore, less common in women, and it wouldn’t explain her thrombocytopenia. Have you had fever? Good choice! PATIENT RESPONSE: No . COMMENT: This question is relevant because it may help you to determine if the patient has an infection, inflammation, or fever associated with TTP.
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