| WBC | 7,500/mm3 | (nl = 5000-11000) | ||
| Hgb | 6.5 g/dL | (nl = 12-14) | ||
| Hct | 19% | (nl = 36-42) | ||
| MCV | 60 mm3 | (nl = 80-96) | ||
| RDW | 19% | (nl = <15) | ||
| platelet count | 590,000/mm3 | (nl = 150,000-450,000) | ||
| erythrocyte count | 2.2 x 1012/L | (nl = 3.8-5.1) |
Judy Wolf is a 33 year old patient with a history of Systemic Lupus Erythematosis (SLE) that has manifested itself as painful joints in her hands and knees. She has had the diagnosis of SLE for 4 years. Her diagnosis was made by a positive ANA, as well as the presence of mild thrombocytopenia (platelet counts 90-110,000) and the presence of a malar rash. She has been taking ibuprofen 800 mg every 6 hours by mouth for her arthralgias for the past several weeks. She presents to your office complaining of extreme fatigue and dyspnea on exertion that has gradually worsened over the past two weeks.
What is going on here?
Is there any other history that you would want?
What things do you want to look for on physical examination?
On Physical examination, Judy is a well-developed, well nourished woman who appears comfortable but somewhat short of breath. Her vital signs reveal a pulse of 110 that is regular, her respiratory rate is 20 and her blood pressure is 110/70. When you stand her up, her pulse increases to 140 and her blood pressure falls to 90/60. Her conjunctivae are pale as are her nail beds. Her heart exam reveals a tachycardia without murmurs rubs or gallops. Her lungs are clear to auscultation. The remainder of her examination is normal.
How has the physical examination helped you?
What is meant by the change in pulse and blood pressure upon standing?
What laboratory tests are you interested in?
You obtain an EKG which is unremarkable except for a sinus tachycardia. Her CBC is remarkable for:
|
Peripheral Smear
|
What is this information telling you?
What do you want to do next?
After looking at her peripheral blood smear, what is your diagnosis?
What laboratory test(s) can confirm your diagnosis?
How should she be treated?
Two years later, Judy again reports to your office with similar complaints of dyspnea on exertion and malaise. You repeat her CBC which reveals the following:
|
Peripheral Smear
|
What is going on now?
How would you confirm your diagnosis?
How should she be treated now?
The primary purpose of this exercise is to demonstrate some of the different types of anemias that can be seen in clinical practice. As well, this case demonstrates the importance of looking at the peripheral blood smear in order to make a diagnosis. Work up and management of anemias is also discussed.
Recognize some of the common physical findings seen in patients with anemia.
Understand the importance of looking at a peripheral smear to diagnose the etiology of anemia.
Interpret a CBC to construct a differential diagnosis of anemia.
Recognize the peripheral smear findings in both iron deficiency anemia and autoimmune hemolytic anemia.
Explain the workup and treatment of iron deficiency anemia and autoimmune hemolytic anemia.