Triage: Sent from PCP office for low hemoglobin

History of Present Illness: A man in his mid 60’s is sent to the ED with two weeks of exertional chest pain and SOB.  Episodes last about 5 minutes and are relieved by rest.  He has a history of HTN but denies any other medical problems.  He does not smoke or drink.  He saw his doctor recently and had blood work done.  The hemoglobin came back low at 8 so he was sent to the ER.  He gets blood work done annually and denies melena or a history of anemia.

Vital Signs: Vital signs are all completely normal

Physical Exam: Physical exam is normal including a guaiac test

Initial Diagnostic Testing:

  • CBC: WBC 6 with normal morphology, Hb 8.3 with macrocytosis (MCV 99), Plt 100
  • EKG and Troponin-i: normal
  • Chemistries: normal including LFT’s
  • Imaging: CXR normal

What is the most likely cause of the anemia?

  • A) Intermittent GI bleed
  • B) Alcoholism
  • C) Malignancy
  • D) Thalassemia

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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ANSWERS: What is the most likely cause of the pain?

  • A) Intermittent GI bleed
  • B) Alcoholism
  • C) Malignancy – CORRECT
  • D) Thalassemia

1-Minute Consult on this topic:

MACROCYTIC w/ HYPER-SEGMENTED NEUTROPHILS        

  • Folate:         Diseases: liver disease, hemolysis                                          Diet/Meds: EtOH/malnutrition, meds (HIV & cancer meds)
  • B12:             Diseases: IBD, tapeworm, bowel resection, gastric bypass   Diet/Meds: vegetarian/vegan, metformin, PPI or H2 blocker, Dilantin
  • PA:               Pernicious Anemia: numb, glossitis, cord: posterior columns

MACROCYTIC w/o HYPER-SEGMENTED NEUTROPHILS     

  • Marrow:         Marrow Failure: aplastic, myelodysplasia, leukemia, chemo,
  • Other:             Thyroid, HIV meds, alcohol

CASE CONCLUSION: Got a call from the lab that there were immature WBC’s and Auer rods present consistent with aggressive myelodysplastic syndrome