Question

F.A. is an 80-year-old man who presents to the Veterans Administration Hospital for a routine checkup. Upon questioning, he states that he "has been feeling weak and terrible" for nearly six months now but has not experienced any weight loss. W.L. says "I've been feeling really lousy lately. I have no energy whatsoever and I'm always cranky." Previous Medical History: • Multiple DVT with chronic venous insufficiency • Type 2 DM • HTN • Hyperlipidemia • Prostate cancer S/P prostatectomy • S/P CVA • DJD; hip fracture 7 years ago; chronic pain in lower back and right buttock • Mild memory loss • Chronic allergic rhinitis • Seizure disorder for 17 years; no seizures with phenytoin (100 mg) in 3 years • COPD for 11 years Further assessment of the patient reveals: • Retired at age 62 after 42 years as a coal miner • Long-term history of cigarette use, which continues at 10 cigarettes/day • Heavy EtOH use (mostly beer) on and off for 15 years, which continues • Very little physical activity Vital Signs: BP = 130/85, Resp. Rate = 18 bpm, BMI = 28.1, Pulse = 110 bpm, Temp = 97.8°F, arterial O2 sat. = 95.5% Decreased breathing sounds bilaterally with diffuse inspiratory and expiratory wheezes bilaterally. Normal thyroid. Patient has some difficulty focusing. Also, pallor is prominent on skin and oral mucosa, slightly noticed in conjunctiva. Intact vibratory sensation. Negative for the following: headache, swelling of ankles, chest pain, anorexia, sore mouth/tongue, lightheadedness, pain with swallowing, muscle/abdominal pain, diarrhea, bruising or bleeding, bruits, jaundice, glossitis, SOB (shortness of breath), JVD (jugular venous distension), lymphadenopathy, bruits, splenomegaly, hepatomegaly, paresthesias, clubbing, cyanosis, and ataxia. Various Laboratory Blood Test Results: Electrolytes (Na, K, Cl, HCO3, Ca, Mg) all normal Kidney function tests: BUN = high normal, Cr = normal LDL = 99 mg/dL, HDL = 30 mg/dL, Cholesterol = 194 mg/dL Liver function tests: AST, ALT, Alk phos = normal; Bilirubin = high normal, Albumin = low normal Fasting Glucose = 185 mg/dL Hb = 8.8 g/dL Hct = 19.7% RBC = 3,000,000/mm3 WBC = 4,400/mm3 Plt = 139,000/mm3 MCV = 103 fL MCHC = 33.5 g/dL Fe = 67 microgram/dL TIBC = 312 microgram/dL Transferrin saturation = 39% Ferritin = 124 ng/mL Vitamin B12 = 230 picogram/mL Folate = 1.7 ng/mL HbA1c = 9.3% TSH = 3.97 microUnits/mL (normal) Peripheral Blood Smear: • Anisocytosis + poikilocytosis • Large neutrophils with 6–7 segments • Macrocytic, normochromic RBCs ANSWER THE FOLLOWING Examine the test result values and identify those that are abnormal. What type of anemia should F.A. be diagnosed with? What symptoms are consistent with your diagnosis? List the signs (vital and others) that are consistent with anemia in general. Be sure to explain why each sign occurs. List the signs that are specific to only this type of anemia and explain why each occurs. What was the single crucial test result that absolutely confirmed the specific type of anemia?

          F.A. is an 80-year-old man who presents to the Veterans Administration Hospital for a routine checkup. Upon questioning, he states that he "has been feeling weak and terrible" for nearly six months now but has not experienced any weight loss. W.L. says "I've been feeling really lousy lately. I have no energy whatsoever and I'm always cranky."

Previous Medical History:
• Multiple DVT with chronic venous insufficiency
• Type 2 DM
• HTN
• Hyperlipidemia
• Prostate cancer S/P prostatectomy
• S/P CVA
• DJD; hip fracture 7 years ago; chronic pain in lower back and right buttock
• Mild memory loss
• Chronic allergic rhinitis
• Seizure disorder for 17 years; no seizures with phenytoin (100 mg) in 3 years
• COPD for 11 years

Further assessment of the patient reveals:
• Retired at age 62 after 42 years as a coal miner
• Long-term history of cigarette use, which continues at 10 cigarettes/day
• Heavy EtOH use (mostly beer) on and off for 15 years, which continues
• Very little physical activity

Vital Signs: BP = 130/85, Resp. Rate = 18 bpm, BMI = 28.1, Pulse = 110 bpm, Temp = 97.8°F, arterial O2 sat. = 95.5%

Decreased breathing sounds bilaterally with diffuse inspiratory and expiratory wheezes bilaterally. Normal thyroid.

Patient has some difficulty focusing. Also, pallor is prominent on skin and oral mucosa, slightly noticed in conjunctiva. Intact vibratory sensation.

Negative for the following: headache, swelling of ankles, chest pain, anorexia, sore mouth/tongue, lightheadedness, pain with swallowing, muscle/abdominal pain, diarrhea, bruising or bleeding, bruits, jaundice, glossitis, SOB (shortness of breath), JVD (jugular venous distension), lymphadenopathy, bruits, splenomegaly, hepatomegaly, paresthesias, clubbing, cyanosis, and ataxia.

Various Laboratory Blood Test Results:
Electrolytes (Na, K, Cl, HCO3, Ca, Mg) all normal
Kidney function tests: BUN = high normal, Cr = normal
LDL = 99 mg/dL, HDL = 30 mg/dL, Cholesterol = 194 mg/dL
Liver function tests: AST, ALT, Alk phos = normal;
Bilirubin = high normal, Albumin = low normal
Fasting Glucose = 185 mg/dL
Hb = 8.8 g/dL
Hct = 19.7%
RBC = 3,000,000/mm3
WBC = 4,400/mm3
Plt = 139,000/mm3
MCV = 103 fL
MCHC = 33.5 g/dL
Fe = 67 microgram/dL
TIBC = 312 microgram/dL
Transferrin saturation = 39%
Ferritin = 124 ng/mL
Vitamin B12 = 230 picogram/mL
Folate = 1.7 ng/mL
HbA1c = 9.3%
TSH = 3.97 microUnits/mL (normal)

Peripheral Blood Smear:
• Anisocytosis + poikilocytosis
• Large neutrophils with 6–7 segments
• Macrocytic, normochromic RBCs

ANSWER THE FOLLOWING
Examine the test result values and identify those that are abnormal.
What type of anemia should F.A. be diagnosed with?
What symptoms are consistent with your diagnosis?
List the signs (vital and others) that are consistent with anemia in general. Be sure to explain why each sign occurs.
List the signs that are specific to only this type of anemia and explain why each occurs.
What was the single crucial test result that absolutely confirmed the specific type of anemia?

Added by Jose Ramon B.

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