Moderator ventana Posted May 1, 2014 Moderator Share Posted May 1, 2014 This is on C1 and not getting much attention so I figured I would post here for some more thoughts - I am not the original poster - but I am posting a link to this topic in hopes the poster will view and pipe in.... (pun intended;-) I am a PA-C at a urban community health clinic with a patient population of mostly Hispanics and with no insurance usually. A 56 yo Hispanic male presented to the clinic as a new patient with cc of right hand and wrist “swollen red and tender”. He denied any trauma to the area. He gave a history of gout and previously on Zyloprim from a MD in Mexico. He also gave a history of HTN and was self treating with Enalapril bought OTC in Mexico. His vitals 97.6, 73 BPM, 159/88, 67 in 202 lb BMI 31.63 meds are Cranberry plus C and Ginger 500mg one each daily Exam Stocky muscular 56 yo obese male Heent NL Lungs CTA CV rrr no M Right upper ext with slight erythema minimal edema moderate tenderness Full ROM all joints pulses 1+ equal good cap refill. Abd obese No HSM appreciated Labs show WBC 4.4 RBC 7.69 HH Hgb 14.4 Hct 45.1 platlets 189 mcv 49 L MCH 18.7 L RDW 17.7 L Alk Phos 134 H otherwise all labs WNL Erythrocythemia aka Erythrocytosis but does not meet criteria for PCV by WHO standards. I have found little on isolated red blood cell elevation. Any input on this case would be welcome. Thanks Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 1, 2014 Share Posted May 1, 2014 What I find more interesting is the erythrocytosis with the significantly low MCV. Students: Ddx of microcytosis? Particularly interesting without corresponding anemia.... Link to comment Share on other sites More sharing options...
cinntsp Posted May 1, 2014 Share Posted May 1, 2014 Thalassemia vs. IDA? It's normal to have elevated RBCs in anemia. Low MCV + high RDW. We need a ferritin level. Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 1, 2014 Share Posted May 1, 2014 Very good overview article here: http://www.aafp.org/afp/2010/1101/p1117.html Link to comment Share on other sites More sharing options...
SocialMedicine Posted May 1, 2014 Share Posted May 1, 2014 is this swelling/erythema acute ? I would think cellulitis or much less likely thrombosis. im not sure I would have run any tests is the soft tissue was tender/erythematous/mild edematous and perhaps started oral ABX cephalexin perhaps ?. Also during exam make sure nothing suggested septic joint. gouty arthritis can affect joints other than first metatarsal. so I guess that is a thought. perhaps I would have checked uric acid, ESR, CBC if I was not convinced of a cellulitis clinical diagnosis. Maybe the HPI needs expansion but Im not seeing the zebra here. History of prior similar swelling ? Malaise/fever ? DVT personal or family hx ? uptodate on cancer screenings ? How long has this been present and what is the symptom trend ? IVDA ? Recent surgery/plane travel etc ? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 1, 2014 Share Posted May 1, 2014 Thalassemia vs. IDA? It's normal to have elevated RBCs in anemia. Low MCV + high RDW. We need a ferritin level. What are you basing your anemia suspicion on if one has a normal Hb. (as in this example) and elevated RBC? By definition, anemia is a reduction from normal in either one or both values. This scenario is also missing the MCHC (I presume it was normal since statement is made that all other values were "WNL"). I don't know this to be the case in this situation but look at your side effects of medication as well as the possibility of a misdiagnosis of a condition. Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 1, 2014 Author Moderator Share Posted May 1, 2014 he zebra is the fact he has an MCV in the 40's!!!!!!!!!!!!, normal H:H, and slight elevated RBC mass this is not a simple red arm or swelling - this is the "hard medicine" that needs thought.... the swelling and arm/wrist pain - that might not be related, might be....... I agree with prima - microcyctosis is an issue and one that should not just be signed off on before you figure out what is going on... Correction on wuthchris - RDW is LOW not high - would expect elevated RDW in some anemias (which ones?) and what does it mean in simple terms What causes smally RBC with out anemia? (think think) Students pipe in with some text book answers if you please...... Anemia are confusing but cool in my book! what does an elevated Ferritin mean clinically in this case?? Link to comment Share on other sites More sharing options...
cinntsp Posted May 1, 2014 Share Posted May 1, 2014 Correction on wuthchris - RDW is LOW not high - would expect elevated RDW in some anemias (which ones?) and what does it mean in simple terms An RDW of 17.7 is high. Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
cinntsp Posted May 1, 2014 Share Posted May 1, 2014 What are you basing your anemia suspicion on if one has a normal Hb. (as in this example) and elevated RBC? By definition, anemia is a reduction from normal in either one or both values. This scenario is also missing the MCHC (I presume it was normal since statement is made that all other values were "WNL"). I don't know this to be the case in this situation but look at your side effects of medication as well as the possibility of a misdiagnosis of a condition. Anemias can present early on with rather benign lab values. The elevated RDW, low MCV, and high RBC(compensatory response) make ruling out IDA reasonable, especially if we are thinking along the lines of other conditions like thalassemia. IDA can produce an MCV in the 40s. So can something like lead poisoning. Ferritin and a manual diff should be done. The MCHC would be helpful to rule out spherocytosis as well, but it's unlikely in this case.. Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
cinntsp Posted May 1, 2014 Share Posted May 1, 2014 Double post Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 1, 2014 Share Posted May 1, 2014 Ferritin is indeed indicated to narrow the differential, HOWEVER I remind you there is no anemia. That's the interesting point here. Remember ferritin is an acute phase reactant and can be elevated in inflammatory conditions as well. Back to the article I posted...look at it. Link to comment Share on other sites More sharing options...
SocialMedicine Posted May 1, 2014 Share Posted May 1, 2014 what I am getting at is I never would have thought to run a CBC in someone wit that chief complaint. So what I was wondering is why all that lab work was ordered for an acute what seems to be cellulitis. I agree the MCV of 40 should be looked into further, but I am not going to figure out the MCV issue prior to treating an acute complaint which is likely unrelated. Although I am guessing the reason why the case is presented is bc they are related ha. I would still like my questions answered and I will add a repeat CBC to make sure there is no lab error and a HGBopathy profile which I can add given the tubes the lab already has. There will be sufficient blood. Link to comment Share on other sites More sharing options...
cinntsp Posted May 1, 2014 Share Posted May 1, 2014 Ferritin is indeed indicated to narrow the differential, HOWEVER I remind you there is no anemia. That's the interesting point here. Remember ferritin is an acute phase reactant and can be elevated in inflammatory conditions as well. Back to the article I posted...look at it. To clarify my earlier point, it is possible to have iron deficiency without anemia and that is how it presents early on. Ferritin will decrease before hemoglobin does. I think the important thing in this patient is that it be ruled out to pursue other ddx. Ferritin needs to be done regardless. Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 1, 2014 Author Moderator Share Posted May 1, 2014 An RDW of 17.7 is high. Sent from my Nexus 5 using Tapatalk by the original post RDW 17.7 L more info - - http://emedicine.medscape.com/article/2098635-overview Ferritin (as prima says) is an acute phase reactant LOW helps with IRON DEF ANEMIA (meaning they have to be anemic first - which he is not Why get a cbc? No idea - I did not see the patient but it was ordered so now we are looking at the results and ordering the test created more questions then answers....... a side lesson - think before you order! repost from prima - - very good overview article here: http://www.aafp.org/...1101/p1117.html AAFP has some great resources on the web pages - keep it bookmarked Link to comment Share on other sites More sharing options...
cinntsp Posted May 1, 2014 Share Posted May 1, 2014 by the original post RDW 17.7 L more info - - http://emedicine.medscape.com/article/2098635-overview Ferritin (as prima says) is an acute phase reactant LOW helps with IRON DEF ANEMIA (meaning they have to be anemic first - which he is not Why get a cbc? No idea - I did not see the patient but it was ordered so now we are looking at the results and ordering the test created more questions then answers....... a side lesson - think before you order! repost from prima - - very good overview article here: http://www.aafp.org/...1101/p1117.html AAFP has some great resources on the web pages - keep it bookmarked It would have helped to have the units. RDW is generally reported, at least in my experience, as a percentage...where 17.7 would be high. Apparently this was posted in fL, which would change everything. I assumed there was a typo so my mistake! Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 1, 2014 Share Posted May 1, 2014 I would have ordered the CBC. If a leukocytosis I'm thinking inflammatory or infectious based on differential. Helps if cellulitis etc. of course would be elevated with gout too but more modestly. I have indeed seen gout affect the majority of an extremity or a large joint--it helps if there are obvious tophi or previous arthritic changes, but often the diagnosis is unclear and we treat empirically for the dangerous (cellulitis), r/o the very serious and possibly dangerous (thrombosis), meanwhile treating the pain and inflammation. Whether this is gout or cellulitis, I expect ferritin to be HIGH (again, acute phase reactant). Now, I'm not totally ignoring Chris's iron deficiency theory, but I think it's much less likely in this situation. Still waiting for someone to give a Ddx of microcytosis. I could give it to you but where's the fun in that?! Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 1, 2014 Author Moderator Share Posted May 1, 2014 PA-S care to venture a guess? Anyone? Link to comment Share on other sites More sharing options...
cinntsp Posted May 1, 2014 Share Posted May 1, 2014 Now, I'm not totally ignoring Chris's iron deficiency theory, but I think it's much less likely in this situation.Still waiting for someone to give a Ddx of microcytosis. I could give it to you but where's the fun in that?! I never thought it was IDA...only part of the microcytosis ddx. I find it even less likely now that the RDW situation is clear. :) Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 1, 2014 Share Posted May 1, 2014 Still waiting on a differential. Link to comment Share on other sites More sharing options...
rcdavis Posted May 1, 2014 Share Posted May 1, 2014 Oh for Pete's sake.. This is not rocket science.. Where are all you guys equal to physicians, not needing physician collaboration.. This case comes into your office, what are you thinking of? What is your ddx? There IS. Something interesting here.. MUCH. More interesting than Fe deficiency... Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 1, 2014 Share Posted May 1, 2014 I love you Davis ???? Link to comment Share on other sites More sharing options...
Joelseff Posted May 2, 2014 Share Posted May 2, 2014 Did anyone bother to check a urate? Sent from my SAMSUNG-SGH-I537 using Tapatalk Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 2, 2014 Share Posted May 2, 2014 I would also expand beyond gout to include all inflammatory arthropathies. Link to comment Share on other sites More sharing options...
Joelseff Posted May 2, 2014 Share Posted May 2, 2014 I would also expand beyond gout to include all inflammatory arthropathies. Definitely....I think the microcytosis is a red herring, dont you? Sent from my Galaxy S4 Active using Tapatalk. Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 2, 2014 Share Posted May 2, 2014 Nope. Link to comment Share on other sites More sharing options...
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