STUDENT COPY

MHD I, Session IX Student Copy – Page 1
CASE-BASED SMALL GROUP DISCUSSION
MHD I
SESSION IX
November 5, 2014
STUDENT COPY
MHD I, Session IX Student Copy – Page 2
CASE 1:
Chief Concern: Feeling weak for months
A 25 year-old woman presents to a clinic with the chief complaint of easy fatigability for
many months. She is currently 24 weeks pregnant with her 3rd child in 4 years. She has
not taken prenatal vitamins or supplements regularly during any of her pregnancies.
Lately, she has developed a taste for eating ice. She has no other complaint. She has
no significant past medical history. Her mother is alive and without medical problems.
Her father died of cause unknown to her. Her siblings have no significant diseases that
she knows of. She does not smoke or drink. Physical examination is positive for pale
conjunctiva and mild spooning of nails.
LABORATORY DATA
Heme Final - M49728
CBC w/Diff
WBC
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW
Plt Count
8.3
2.99
7.1
22.0
74
23.6
32.7
17.1
450
L
L
L
L
L
H
H
[4.0-10.0] k/ul
[3.60-5.50] m/ul
[12.0-16.0] gm/dl
[34.0-51.0] %
[85-95] fl
[28.0-32.0] pg
[32.0-36.0] gm/dl
[11.0-15.0] %
[150-400] k/ul
EDUCATIONAL OBJECTIVES
1. Based on the CBC, how would you characterize this anemia?
2. What is the differential diagnosis for the etiology of this anemia based on the CBC?
What does the RDW represent and how does it help in narrowing the differential?
How does the RBC count help in narrowing the differential?
MHD I, Session IX Student Copy – Page 3
A reticulocyte count is ordered.
Auto Retic Cnt
Uncorr Retic
Absolute Retic Count
2.5
69,000
%
/mm3
3. How does a reticulocyte count help categorize the anemia? What are reticulocytes?
How are reticulocytes counted?
4.
How is the corrected reticulocyte count calculated? What information do you get from
this value? What is the importance of the absolute reticulocyte count?
5. What do the Mean Corpuscular Hemoglobin (MCH) and Mean Corpuscular
Hemoglobin Concentration (MCHC) signify? Are the values of clinical significance?
6. Serum ferritin, iron, and transferrin are ordered (results below). Why?
What are the uses, interpretation and precautions for serum iron quantitation and total
iron-binding capacity?
MHD I, Session IX Student Copy – Page 4
FERRITIN
3 ng/ml
* * * FERRITIN REFERENCE VALUES * * *
ADULTS
GEOMETRIC 95% REFERENCE
MEAN NG/ML LIMITS NG/ML
NORMAL MALES
94
22-322
NORMAL FEMALES 46
10-291
IRON DEFICIENCY
12
1-35
IRON OVERLOAD
1900
335-8573
RENAL DIALYSIS
312
31-1321
CHRONIC LIVER
DISEASE
1967
8-12826
Iron & Transferrin
Iron
Transferrin
Calc. Iron Binding Cap.
5
357
500
LL
H
H
[42-135] ug/dl
[192-382] mg/dl
[260-480] ug/dl
Comment: calculated iron binding capacity = Transferrin x 1.4
7. Calculate her iron saturation.
anemias?
How useful is iron saturation in the diagnosis of
8. What is ferritin? How do you interpret low and high ferritin values?
9. Based on the information available, make a complete diagnosis of her anemia.
10.
Could she have 'anemia of chronic disorder'? What are the known mechanisms of
anemia of chronic disorder?
MHD I, Session IX Student Copy – Page 5
11.
What is the daily requirement of iron for a normal adult? Is it different for females
or pregnant women?
12.
In which part of the GI tract is iron absorbed? What else is necessary for iron
absorption?
13.
What treatment would you prescribe for this patient, and for how long? Are there
common side effects of this therapy?
14.
In addition to containing iron, most prenatal vitamins have ~ 400mg of folic acid.
Explain the rationale.
15.
Review the Case Image.
Hematology, Set 1
MHD I, Session IX Student Copy – Page 6
CASE 2
The patient is a 76 year old man who presents to his doctor because his feet “feel
funny”. Sometimes it feels as if “pins and needles” are being stuck in his legs.
His wife accompanies him and adds that he seems more forgetful (although the patient
comments “no more forgetful than you dear”.)
His past medical history is significant for hypertension, osteoarthritis affecting his hips
and knees and a bleeding ulcer for which “part of my stomach was removed” some
years ago.
His medications include hydrochlorothiazide 25mg daily and acetaminophen 500mg four
times daily as needed for pain.
He has never smoked. He does not drink alcohol.
On physical examination he is alert and oriented.
Blood pressure 114/72, pulse 80 beats per minute and regular, respiratory rate 16. He is
afebrile. Oral mucosa is moist without ulcerations, however, the patient’s tongue
appears smooth and shiny.
Heart and lung exams are unremarkable.
There is a well-healed midline vertical upper abdominal surgical scar. His bowel sounds
are normoactive. There is no hepatosplenomegaly or masses palpated.
Neurologic examination of the upper extremities is normal. Strength in his bilateral feet
is 5/5. There is symmetrical decreased vibration and position sense of his feet.
He scores 26/30 on mini-mental status examination.
Laboratory Data
Heme Final - F45572
CBC w/Diff
WBC
RBC
Hgb
Hct
MCV
RDW
Plt Count
Manual Diff
Gran
Gran #
Lymph
Lymph #
Mono
Mono #
Eo
Eo #
Baso
Baso #
4.1
3.44
9.1
27.3
112
15.3
149
48
1.9
40
1.6
7
0.3
4
0.2
1
0.1
L
L
L
L
HH
H
L
[4.0-10.0] k/up
[3.60-5.50] m/ul
[12.0-16.0] gm/dl
[34.0-51.0] %
[85-95] fl
[11.0-15.0] %
[150-400] k/ul
[45-70] %
[2.0-7.0] k/mm3
[20-45] %
[1.0-4.0] k/mm3
[0-10] %
[0.0-1.0] k/mm3
[0-7] %
[0.0-0.7] k/mm3
[0-2] %
[0.0-0.2] k/mm3
The peripheral smear is reviewed by the physician and laboratory technologist. Many
neutrophils with greater than 5 lobes are seen.
MHD I, Session IX Student Copy – Page 7
Auto Retic Cnt
Uncorr Retic
Corr Retic %
Absolute Retic Count
2.3
1.4
44,000
%
%
/mm3
EDUCATIONAL OBJECTIVES
1.
Based on the CBC, how would you characterize this anemia?
2.
What is the differential diagnosis for the etiology of this anemia?
3.
How does the reticulocyte count help categorize the anemia?
4.
What is the significance of the finding on the peripheral blood smear?
MHD I, Session IX Student Copy – Page 8
5.
What, if any, additional laboratory data would you order to render a diagnosis?
(Your facilitators will provide you with the results).
While you are awaiting the tests results, what do you think is the most likely
diagnosis based on the clinical and laboratory data provided thus far?
6.
How do patients acquire this disease? This patient?
7.
Review the Case Images.
Hematology, Set 2
MHD I, Session IX Student Copy – Page 9
Case 3
History of Present Illness:
A 49-year-old woman with Systemic Lupus Erythematosus presents to her physician’s
office with shortness of breath and fatigue. She has had no cough or chest pain and no
fevers or significant changes in weight. Her bowel movements have been brown and she
notes no melena or hematochezia.
Past Medical History:
Systemic Lupus Erythematosus (SLE) diagnosed 3 years ago. Her rheumatologist moved
out of state 1 year ago and she has not yet established care with another.
Depression
Hysterectomy at age 41 secondary to “heavy bleeding from fibroids”
Medications:
None – several months ago she ran out of the medications her rheumatologist had
prescribed and currently cannot remember their names.
Social History:
The patient rarely drinks alcohol – her last drink was 4 months ago.
She smoked cigarettes in her 20’s - about 1 pack/day of cigarettes for 5 years.
Physical Exam:
Vitals: BP 124/72, Pulse 98 , Respiratory rate 14/minute, temp 98.0F
Pulse oximetry – 97% on RA
General: The patient is thin. She appears in no distress.
Eyes: Anicteric
Mouth: few dental caries, no ulcers
Neck: no lymphadenopathy
Lungs: decreased breath sounds at the bases, otherwise clear to auscultation. Bibasilar
dullness to percussion at the bases.
Heart: normal S1S2, regular, I/VI systolic murmur LLSB, no radiation, no rub or
gallop
Abdomen: normoactive bowel sounds, soft, nontender, no hepatomegaly, spleen tip
palpable, no masses
Rectal exam: normal sphincter tone, stool brown, occult blood negative
Extremities: no edema of the legs bilaterally, no calf tenderness
Vascular: normal dorsalis pedis, radial, and carotid pulses
Musculoskeletal: Moderate tenderness, erythema and swelling of the right second and
third metacarpophalangeal joints bilaterally
Skin exam: maculopapular erythema over the cheeks which spares the nasolabial folds
bilaterally
Neurologic Exam: no focal weakness or other neurologic signs
The physician forms a differential diagnosis for the patient’s chief complaints of dyspnea
and weakness and initially orders the following:
MHD I, Session IX Student Copy – Page 10
CBC w/Diff
WBC
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW
Plt Count
Manual Diff
Gran
Gran #
Lymph
Lymph #
Mono
Mono #
Eo
Eo #
Baso
Baso #
3.9
3.44
8.1
24.3
86.5
27.3
32.7
14.1
137
`
73
2.8
14
0.5
7
0.3
4
0.16
1
0.1
[4.0-10.0] k/ul
[3.60-5.50] m/ul
[12.0-16.0] gm/dl
[34.0-51.0] %
[85-95] fl
[28.0-32.0] pg
[32.0-36.0] gm/dl
[11.0-15.0] %
[150-400] k/ul
[45-70] %
[2.0-7.0] k/mm3
[20-45] %
[1.0-4.0] k/mm3
[0-10] %
[0.0-1.0] k/mm3
[0-7] %
[0.0-0.7] k/mm3
[0-2] %
[0.0-0.2] k/mm3
Complete Metabolic Panel
Glucose
97
Blood Urea Nitrogen 16
Creatinine
0.8
Calcium
8.9
Sodium
140
Potassium
4.0
Chloride
102
Carbon Dioxide
28
Albumin
3.1
Protein, Total
5.8
Alkaline Phosphatase 78
AST
35
Bilirubin, Total
1.9 H
ANA SCREEN:
POSITIVE
TEST PERFORMED USING HEP 2 CELLS
REFERENCE RANGE: NEGATIVE
ANA TITER:
1:1280
ANA PATTERN:
SPECKLED
[70 – 100]
[7 - 22]
[0.7 - 1.4]
[8.5 - 10.5]
[136 - 146]
[3.5 - 5.3]
[98 - 108]
[20 - 32]
[3.6 - 5.0]
[6.2 - 8.0]
[25 - 215]
[5 - 40]
[0.2 - 1.4]
mg/dl
mg/dl
mg/dl
mg/dl
mmol/L
mmol/L
mmol/L
mmol/L
gm/dl
gm/dl
IU/L
IU/L
mg/dl
MHD I, Session IX Student Copy – Page 11
LEARNING OBJECTIVES:
1.
Develop a diagnosis for the etiology of the patient’s anemia.
2.
A reticulocyte count is ordered - why?
Auto Retic Cnt
Uncorr Retic
Corr Retic %
3.9
2.3
%
%
Absolute Retic Count
102,000
/mm3
Additional Laboratory Tests:
LDH
365 U/L
Haptoglobin <10mg/dL
(92-202 U/L)
(50-220 mg/dL)
The peripheral blood smear is reviewed and shows anisopoikilocytosis, polychromasia,
and spherocytes
3. Why were the additional laboratory tests ordered? Explain and interpret the results.
4. The physician orders a direct antiglobulin test (DAT) (also known as direct Coomb’s
test). Why?
MHD I, Session IX Student Copy – Page 12
Describe the DAT.
List conditions associated with hemolysis and a positive DAT result and conditions
associated with hemolysis and a negative DAT result.
The direct Coomb’s test was strongly positive for IgG.
5.
What is your diagnosis? Is there an association of this disease process with SLE?
6.
What other clinical features of SLE does this patient have?
7.
Review the Case Image – Hematology Set 3
Case 4 Unknown
Students will not have case data until the session meets
****

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