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URI & Anemia

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History of Present Illness:

A 12-year-old female presents to the ED for 2 weeks of cough and persistent and worsening fevers, up to 103.3 in the past 3 days. ?She has a mild headache but no neck stiffness, photophobia or vomiting. ?She has a mild cough but no shortness of breath. ?She has a mild sore throat which is improving.  Here parents say she has lost her color.  She denies any melena, vomiting, rectal bleeding or heavy menses.

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse of 113.  Physical exam is normal except for tachycardia and mild palor.  Lungs are clear and the throat looks normal.

Initial Differential Diagnosis:

  • Pneumonia
  • Mono
  • SYPHILIS THE GREAT (imitator)

Initial Diagnostic Testing:

  • UA, CXR and BMP are normal
  • AST and ALT are both elevated at 152 and 162
  • CRP and ESR are normal
  • CBC is normal except for a Hb of 5.2 with an MCV of 112.  Of interest her WBC count is also 5.2 with 72% lymphocytes

QUESTIONS:

  1. What should you do next?  
  2. Want a 1-minute consult/tutorial on this case? 
  3. Want to know what happened with this patient?

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ANSWERS:

  1. What should you do next?  Consult hematology.
  2. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  3. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: Admitted.  Workup showed +EBV IgM as well as a mild hemolytic anemia, with elevated LDH but no shistocytes.   No cause of hemolysis was found by hematology other than the  mononucleosis.  Steroids were considered, but her hemoglobin gradually rose by just under 1 gram/day.

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