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A 61-year-old previously healthy male presents to the primary care clinic for fatigue and generalized weakness for 3 months.  Upon questioning, he reports that he tires more easily when walking uphill or when climbing more than two flight of stairs.  All of the symptoms have slowly worsened over time.  He has no significant past medical or surgical history.  He takes a multivitamin but does not take any over the counter or prescription medications.  He consumes a normal, well-rounded diet.  

Social History:  works full time in IT and lives with long term partner.  Never smoked, drinks 1-2 glasses of wine or beer per day, no recreational drug use.

Review of systems (ROS):

General: denies weight changes, fever or malaise

Skin: denies rash or jaundice

Resp: Denies cough, wheezing, orthopnea, or history of asthma

Cardiac: denies lightheadedness, fainting, chest pain, lower extremity edema, or palpitations

GI: denies abdominal pain, decreased appetite, nausea, vomiting, heartburn, change in bowel habits, diarrhea, constipation, melena, or hematochezia

MSK: denies joint pain, stiffness or muscle pain

Neuro: denies headache, dizziness, memory problems, numbness, tingling or weakness in his extremities

Psych: denies depression, anxiety, insomnia or recent stressors.  He sleeps 7-8 hours per night. 

Health care maintenance: His immunizations are up to date.  His last routine physical, CBC, CMP, PSA and lipid panel were normal 16 months ago.  He had a normal colonoscopy 5 years ago.   

His vital signs and physical exam are normal, with the exception of a positive fecal occult blood test on digital rectal exam.  His ECG, complete metabolic panel (CMP), thyroid stimulating hormone (TSH), white blood cell count and platelet count are normal.  Additional lab findings from the CBC are noted:

 

CBC

Result

Reference

RBC

4.4 (106/mm3)

4.3-5.9 (106/mm3)

Hemoglobin

11.5 (g/dL)

14-18 (g/dL)

Hematocrit

36 %

42-52 %

MCV

72 (fL/cell)

80-100 (fL/cell)

MCH

25 (pg/cell)

27-32 (pg/cell)

MCHC

27 (g/dL)

30-35 (g/dL)

RDW

16.1

11.5-14.5 

Reticulocyte count

0.3 %

0.5-1.5%

 

Case Analysis

Is the anemia hypoproliferative or non-hypoproliferative?  Provide the rationale for your answer.
How do you classify this anemia (macrocytic, microcytic, or normocytic)? Explain your answer.
Based on the patient’s symptoms, exam, and lab findings, what is the most likely diagnosis and provide your rationale?  List 2 other differential diagnosis for this class of anemia along with symptoms and clinical findings associated with each.
What additional labs will you order and what findings will confirm or support your diagnosis?
What should be included in the management plan?  Include pharmacologic, non-pharmacologic treatment modalities and indicate if the patient requires additional diagnostics and/or a referral.  
SCIENCE
HEALTH SCIENCE
NURSING

 

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