Joelseff 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. :-) Dont forget your jar of leeches and bottles of castor oil. Lol 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 Don't need the castor oil when I have my Geritol. BTW, it makes a great mixer! Link to comment Share on other sites More sharing options...
cupojava Posted May 3, 2014 Share Posted May 3, 2014 The microcytosis can be from iron deficiency but there is no anemia so I'm going to order iron panel (iron, TIBC, % sat) and wait for results. Can PV and IDA occur at the same time? Maybe the monoarticular arthritis is a thrombotic event from PV?! Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 3, 2014 Share Posted May 3, 2014 Microcytosis can be the result of chronic inflammatory processes as discussed. The OP at the other site shows the alk phos. as being "H" though other reference ranges show it as being normal. For grins and giggles, if this indeed were the case and it were to be elevated then you now have a "chronic inflammatory process" potentially from the liver, resulting in microcytosis. Liver inflammation based upon what? He is self-medicating with an ACEI inhibitor. What about unknown renal disease progression after he's peaked his benefit potential from the ACEI? Remember, there is a point of maximum protection and thereafter you run the risk of a deterioration of renal function as a result of exacerbation from the ACEI. Same thing with elevated uric acid levels clogging the kidneys potentially, thus exacerbating the potential renal disease even further. A ferratin level could still be beneficial due to it's acute inflammatory response (elevation potentially). Any other potential inflammatory source accounting for the hypothetical elevated alk phos? What about osteo in the involved extremity? While it may not be typical, you don't have to have an elevated WBC for there to be an underlying inflammatory/infectious process. Link to comment Share on other sites More sharing options...
Joelseff Posted May 3, 2014 Share Posted May 3, 2014 An isolated borderline/mildly elevated alk p doesnt mean, necessarily, liver injury. I think we can all agree on further studies for this pt including repeat cbc, smac20, urate, ra, ana, ferritin, tibc, and a u/a. 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 I agree, which is why I said potentially. To my recollection no one has mentioned the alk phos.. Link to comment Share on other sites More sharing options...
Guest Paula Posted May 4, 2014 Share Posted May 4, 2014 Don't need the castor oil when I have my Geritol. BTW, it makes a great mixer! And gives you iron. Link to comment Share on other sites More sharing options...
Guest JMPA Posted May 4, 2014 Share Posted May 4, 2014 The microcytosis can be from iron deficiency but there is no anemia so I'm going to order iron panel (iron, TIBC, % sat) and wait for results. Can PV and IDA occur at the same time? Maybe the monoarticular arthritis is a thrombotic even from PV?! the anemia can be masked if the patient is in a dehydrated state. A thorough skin exam and history is essential before shotgun testing. rubor/dolor/tumor? the blood count can be unrelated. the ddx need to be broadened and include insect bites and TB for starters. to comment blindly is a ghost hunt. is there an actual answer to the concluded dx or is this all conjecture? Link to comment Share on other sites More sharing options...
cbrsmurf Posted May 6, 2014 Share Posted May 6, 2014 My money is on thalassemia Hgb and hct are wnl because of the compensatory rbc production. Dx reinforced by low mch and rdw. Would possibly get a retic to make sure. Pt probably could not afford to get a hgb electrophoresis. Possibly get a ferritin/tibc/iron, but if asymptomatic and h/h are wnl, does it matter if IDA? I don't think the wrist issue and hx of gout is related, but not sure. Is hemolysis related to arthropathy? Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 6, 2014 Share Posted May 6, 2014 My money is on thalassemia.... I don't think the wrist issue and hx of gout is related, but not sure. Is hemolysis related to arthropathy? Ah. Now you're on to something grasshopper. What happens with the breakdown products of hemolyzed RBCs? What are they and where do they go? Think of what happens with sickle cell crisis...the principle is relevant. Hmmmmm Link to comment Share on other sites More sharing options...
FfIghter23 Posted May 6, 2014 Share Posted May 6, 2014 ^^ Vaso-occlusive pain from microvascular thrombosis and hence the inflammatory response? All I could think of that happens w/ SSA Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 6, 2014 Share Posted May 6, 2014 Keep thinking. You have a small piece of it. Link to comment Share on other sites More sharing options...
cbrsmurf Posted May 6, 2014 Share Posted May 6, 2014 Ah. Now you're on to something grasshopper. What happens with the breakdown products of hemolyzed RBCs? What are they and where do they go? Think of what happens with sickle cell crisis...the principle is relevant. Hmmmmm Bilirubin -> liver (causing a slightly high alk phos?) -> ??? -> arthropathy. I admit I don't remember my pathophys as well as I should have. I forgot to mention RA can cause microcytosis, so my ddx has expanded to: 1. Thalassemia 2. and/or Rheumatoid Arthritis 3. Erectile dysfunction Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 6, 2014 Share Posted May 6, 2014 I was with ya until #3 lol. A skilled practitioner will have a minimum of 4-5 differentials for the problem at hand. You narrow them down based on H&P and ancillary testing (which should confirm your suspected diagnosis and refute others). You skipped quite a few steps from chewed up RBCs to arthropathy. Back to Biochem and pathophys. ???? Link to comment Share on other sites More sharing options...
Joelseff Posted May 6, 2014 Share Posted May 6, 2014 Bilirubin -> liver (causing a slightly high alk phos?) -> ??? -> arthropathy. I admit I don't remember my pathophys as well as I should have. I forgot to mention RA can cause microcytosis, so my ddx has expanded to: 1. Thalassemia 2. and/or Rheumatoid Arthritis 3. Erectile dysfunction That last one was a Zebra! Lol. Sent from my Galaxy S4 Active using Tapatalk. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 6, 2014 Share Posted May 6, 2014 "Honey, where's the Viagra? My wrist hurts?" ;-). As an aside, FDA shot down prophylactic ASA for CV prevention in virgin patients today. Link to comment Share on other sites More sharing options...
primadonna22274 Posted May 7, 2014 Share Posted May 7, 2014 Yup! I haven't recommended ASA prophy for primary prevention for the last few years. If patients want to take it and don't have CI, fine, but I tell them there's no proven benefit except for secondary prevention. Link to comment Share on other sites More sharing options...
Joelseff Posted May 7, 2014 Share Posted May 7, 2014 "Honey, where's the Viagra? My wrist hurts?" ;-). As an aside, FDA shot down prophylactic ASA for CV prevention in virgin patients today. Where'd u read it about ASA ppx? I'm googling it and nothing. Nevermind found it in Medscape http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm390539.htm Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 7, 2014 Share Posted May 7, 2014 You have to use a more reliable medical source; my local ABC affiliate medical reporter! I actually really appreciate her stories. She tells it like it actually is. As I've said in the past for CV virgins, pick your poison; MI vs. GI bleed. Link to comment Share on other sites More sharing options...
db_pavnp Posted May 12, 2014 Share Posted May 12, 2014 Thread is dead and all, but I am coming to the end of reading Katzung's Clinical Pharmacology and one of the last chapters is Tox. Notable to this patient, lead poisoning is characterized by a normo, micro, or macrocytic anemia with or without basophilic stippling, saturnine gout, and hypertension. There are a host of other symptoms, of course, but couldn't help but wonder if this guy was a sensible presentation of a low dose, chronic poisoning. Link to comment Share on other sites More sharing options...
sk732 Posted May 12, 2014 Share Posted May 12, 2014 Came into this late, but I'd have to consider thallassemia, lead poisonng, hemolysis secondary to reactive G6PD deficiency or SSA causing a vaso-occlusive crisis. Someone was wondering back if Hispanic's were considered Mediterranean - consider the root word of Hispanic as Spain or Spanish and you could be right, since Spain is a Meditterranean country. There may be some genes in the wood pile there causing G6PD issues. Gout is still on there too - seen my fair share of gout in the wrist before...common things happen commonly after all :-). SK Link to comment Share on other sites More sharing options...
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