Joelseff Posted May 2, 2014 Share Posted May 2, 2014 Nope. Hmmmm....lol. guess id better review microcytosis. Figured it was an incidental finding like thallasemia trait... Sent from my Galaxy S4 Active using Tapatalk. Link to comment Share on other sites More sharing options...
SocialMedicine Posted May 2, 2014 Share Posted May 2, 2014 So when I met with the patient yesterday I reviewed a CBC that someone else ordered and decided to add a HGBopathy profile, repeat CBC, ferritin, and reticulocyte count. I also started cephalexin 500MG QID. Has the patient improved ? When did he start enalapril ACEi can bring about an angioedema and the CBC could be an unrelated finding ? Also the patient has not answered any of my questions from yesterday. I am thinking of discharging him for poor compliance. Link to comment Share on other sites More sharing options...
Joelseff Posted May 2, 2014 Share Posted May 2, 2014 So when I met with the patient yesterday I reviewed a CBC that someone else ordered and decided to add a HGBopathy profile, repeat CBC, ferritin, and reticulocyte count. I also started cephalexin 500MG QID. Has the patient improved ? When did he start enalapril ACEi can bring about an angioedema and the CBC could be an unrelated finding ? Also the patient has not answered any of my questions from yesterday. I am thinking of discharging him for poor compliance. In all fairness, the original post was from C1. I think Ventana just put it up here as an exercise for us. Im thinking like you. Dx 1 is cellulits, Dx 2 incidental finding of microcytosis unk etiology. I suppose the microcytosis is Pb poisoning but theres no anemia. Oh well. Waiting for answers. Sent from my Galaxy S4 Active using Tapatalk. Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 2, 2014 Author Moderator Share Posted May 2, 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... DARN that is my point exactly.... come on guys and gals - it is not treating the simple that makes us good - it is knowing when something doesn't smell right and then figuring it out...... Prima and I can not be the only one's on the "gotta get a working Ddx" going here..... with a a DDx we are worthless - well maybe not worthless- but certainly not really any different then a good nurse.... SOAP is 4 parts and so far we are stuck at A...... STUDENTS - pull out those books and come up with a great Ddx.... (or just google microcytosis Ddx if you are lazy....) Link to comment Share on other sites More sharing options...
db_pavnp Posted May 2, 2014 Share Posted May 2, 2014 Feels like cheating once you read up on it. I read some forums that let you hide text in a "spoiler" box which I would use here if I knew how. Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 2, 2014 Share Posted May 2, 2014 There are 5 general causes of microcytosis--at least. Lead poisoning is only one. Expand.... Link to comment Share on other sites More sharing options...
MediMike Posted May 2, 2014 Share Posted May 2, 2014 Thalassemia, Anemia of Chronic Disease, PCV, Iron Deficiency... Only two presenting with erythrocytosis would be PCV and Thalasemia (that I'm aware of) Doesn't really meet criteria for PCV in regards to HgB, next step electrophoresis if ferritin levels came back normal? Okay back to pharm lecture.... Edit: Sideroblastic as well Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 2, 2014 Share Posted May 2, 2014 Thank you MediMike. I knew it would be a fresh student lol. Yes, do the Hb electrophoresis. Remember that anemia of chronic disease (ACD) is really anemia of chronic inflammation. I would be surprised if that's the cause of this patient's microcytosis alone as the MCV is usually more moderate (60-70) in ACD/ACI. But hey, patients get to have more than one problem. Keep talking--after pharm, of course. I like the way you think. Link to comment Share on other sites More sharing options...
MediMike Posted May 2, 2014 Share Posted May 2, 2014 Ferrtin/Transferrin/TIBC levels would be helpful at this point in the exam. ACD/ACI lept out initially with the erythematous joint, would be curious to know if there was a history that pointed towards an autoimmune issue, if I'm correct ACD/ACI would be associated with a normal/high ferritin (body is trying to hide it's Fe from the pathogen/cause is how I remember it) and low transferrin/TIBC/serum levels. Sideroblastic seems unlikely with the erythrocytosis. IDA remains on the ddx until the Fe levels are back. Thalassemia stays up there until electrophoresis. In regards to the hand/wrist, allopurinol can cause skin/joint reactions...not anti-epileptic agents, but still pharm, so this counts as studying right? Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 2, 2014 Share Posted May 2, 2014 Absolutely! Link to comment Share on other sites More sharing options...
Joelseff Posted May 2, 2014 Share Posted May 2, 2014 There are 5 general causes of microcytosis--at least. Lead poisoning is only one. Expand.... I thought the others were given by Chris in an earlier post thats why I didnt rehash the ddx. I was more looking at how the microcytosis is related to the presenting cc which was why I thought it was an incidental finding. Also wanted the PA-Ss to chime in the obvious. 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 It could well be an incidental finding but I still think it must be explained--and could be germane to the case. For instance, there is an arthropathy that occurs with thalassemia. Etc. Link to comment Share on other sites More sharing options...
Joelseff Posted May 2, 2014 Share Posted May 2, 2014 It could well be an incidental finding but I still think it must be explained--and could be germane to the case. For instance, there is an arthropathy that occurs with thalassemia. Etc. I suppose thalassemic osteoarthropathy but I thought that was more for Beta thal Major. This guys labs dont look like thal major...oh well electrophoresis and iron studies are warranted to chase down the microcytosis and should shed more light in the case. I wonder if the original PA on C1 solve it yet? 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 Agree that it's less likely with thal minor. Certainly not beta thal major undiagnosed up to this point. Can also have iron overload disease from multiple transfusions if known thal (that may not have needed treatment...unless thal major they are NOT iron deficient and should not be transfused in most situations. Link to comment Share on other sites More sharing options...
cupojava Posted May 2, 2014 Share Posted May 2, 2014 Oh good Lord. Okay, here are my top SIX Ddx: Monoarticular arthritis--(1) septic arthritis, (2)osteomyelitis, (3) gout but in the the setting of monocytosis without anemia and a high ALP, one needs to dig deeper into the cause. Maybe gout is a sign of the disease. Check out other causes of anemia--(4) Sickle cell, (5) G6Pd or maybe even (6) medications already taking that can unmask certain conditions. I may be deficient in my Ddx. I would may be get Hb electrophoresis. In the HPI, I might ask about dietary intake of certain legumes. In the physical exam, I might want to check the abdomen specifically the spleen. Okay, someone else do the workup. Link to comment Share on other sites More sharing options...
Joelseff Posted May 2, 2014 Share Posted May 2, 2014 I just literally finished seeing a guy with "the Gouch" 5 minites ago......he didnt have microcytosis though but a urate of 8.2...what a coinkydink... Sent from my Galaxy S4 Active using Tapatalk. Link to comment Share on other sites More sharing options...
bradtPA Posted May 2, 2014 Share Posted May 2, 2014 Be interesting to know tobacco usage, too. In NC we get a lot of erothrocytosis related to that..... Link to comment Share on other sites More sharing options...
Acebecker Posted May 2, 2014 Share Posted May 2, 2014 Serum uric acid has a poor correlation to the cause of a monoarticular arthritis. The *only* way to be definitive is to put a needle in it.That said, lead toxicity has the potential to cause a microcytosis and precipitate gout flares. Link to comment Share on other sites More sharing options...
cupojava Posted May 3, 2014 Share Posted May 3, 2014 Okay. I was thinking it was g6pd since gout is associated with this condition and that the meds he is can unmask it; but the lack of response to my ddx makes me think I was going the wrong track. I know that g6pd is usually seen in Mediterraneans but it could happen maybe to Hispanics too? Anyway, I'm gonna go dig up my CMDT. :) BRB Link to comment Share on other sites More sharing options...
Joelseff Posted May 3, 2014 Share Posted May 3, 2014 Okay. I was thinking it was g6pd since gout is associated with this condition and that the meds he is can unmask it; but the lack of response to my ddx makes me think I was going the wrong track. I know that g6pd is usually seen in Mediterraneans but it could happen maybe to Hispanics too? Anyway, I'm gonna go dig up my CMDT. :) BRB I dont think any of us are "wrong" this was from clinician 1 and I dont think the actual PA who saw this guy is on this thread. But it has been interesting seeing everyone's approach/reaction to the case.... Sent from my Galaxy S4 Active using Tapatalk. Link to comment Share on other sites More sharing options...
Derbingle Posted May 3, 2014 Share Posted May 3, 2014 Enjoying all this medicine. Im guessing the reason everyone has honed in on microcytic anmeia is that it is related to dx? I look forward to learning what it is. No cellulits? Able to move fingers without pain I assume. No osteomyelitis either ? Being from ER we wouldnt follow it out this far for iron studies etc and reminds me how much Ive forgotten re: blood dyscrasias/disorders. I look forward to more medicine. Thanks for posting interesting case. Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 3, 2014 Share Posted May 3, 2014 Good thoughts Derbingle. It is interesting to note that the microcytosis is without anemia. Makes the differential a bit more fun :) Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 3, 2014 Share Posted May 3, 2014 C'mon folks. Let's return to the REAL world. We would've looked at the extremity, shook our heads, scanned the lab over 15 seconds, shook our heads again and this time add a scowl to our face for the patient's sake to let them know that we are concerned and thinking hard, and referred to the physician. After all, we're only assistants (well, except for PD soon-to-be D.O.) and we're there to generate cash. Plus, we have to get back to our bourbon whiskey that we've been soaking our instruments in (from another thread). :-) Link to comment Share on other sites More sharing options...
Joelseff Posted May 3, 2014 Share Posted May 3, 2014 C'mon folks. Let's return to the REAL world. We would've looked at the extremity, shook our heads, scanned the lab over 15 seconds, shook our heads again and this time add a scowl to our face for the patient's sake to let them know that we are concerned and thinking hard, and referred to the physician. After all, we're only assistants (well, except for PD soon-to-be D.O.) and we're there to generate cash. Plus, we have to get back to our bourbon whiskey that we've been soaking our instruments in (from another thread). :-) Hahaha ...GMOTM, u need to retire already lol. :-P Sent from my Galaxy S4 Active using Tapatalk. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 3, 2014 Share Posted May 3, 2014 There you go, trying to run off the old geezer. I'm just going to pout and take my "antiseptic" home with me. :-) Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.