Solving Patient Problems

1. Solving Patient Problems • 14 month old boy referred to your clinic after being told by the Health Department at his 1 year check-up that he had “low blood.” • In thinking this through, what is your initial step to this chief complaint?

2. What is the issue presented to you? • What is the question posed to you? • What is “low blood”? • Does this mean “anemia”? • How is anemia defined?

3. Anemia is simply a hemoglobin level lower than the normal range for a particular age and sex of the patient. • What are the consequences of anemia?

4. Anemia results in a decreased oxygen carrying capacity. • How do we broadly classify anemias?

5. Anemiaphysiologic classification • Decreased production • Increased destruction • Blood loss • At this age, what might be some diagnostic possibilities?

6. Differential Diagnoses • Thalassemia • Iron Deficiency • Lead Poisoning • Transient Erythroblastopenia of Childhood • Sickle Cell Disease • Autoimmune Hemolytic Anemia

7. What significant historical questions can focus our search for the ultimate diagnosis?

8. Meds Allergies Surgeries Hospitalizations Perinatal Diet none none none none no congenital infection or jaundice breast fed until 8 months, then milk Past Medical History

9. Environment Recent illnesses Travel Development Chronic diseases Family history no lead known mild URI none normal for age none mother has sickle trait dad unknown Past Medical History (cont)

10. How is your differential altered by this new information? • Can you eliminate or elevate any of the possibilities? • What findings on physical exam would be important?

11. Vital signs Growth General appearance Skin color, perfusion HEENT Respiratory Cardiovascular Abdomen Developmental 99.4 120 90/60 30 Following 50th %ile crying no jaundice, cap refill no scleral icterus clear, no distress RRR, no murmur no mass or HSM normal for age Physical Exam Findings

12. How do these findings alter your potential differential diagnoses? • Now that you have a solid history and physical exam, would any studies be indicated at this point to narrow the differential?

13. Laboratory Studies • CBC with differential • Reticulocyte count • Sickle prep

14. White blood cells Hemoglobin Hematocrit Platelets MCV MCH RDW Reticulocyte count Peripheral smear 6.3 8.0 24 675 62 20 18 2.2 normal Lab Results

15. How do these results alter your diagnostic possibilities? • How would we classify these findings in a morphological way, now that we have red cell morphology results?

16. Anemiamorphological classification • Microcytic • Normocytic • Macrocytic

17. Which of these categories do our lab results best fit?

18. Microcytic, hypochromic • - Iron Deficiency • Thalassemias • Lead Poisoning • Chronic Inlammation • Inflammatory Bowel Diseases (IBD) • Juvenile Rhumatoid Arthritis (JRA) • Severe Protein Deficiency

19. Additional Tools • Any need for iron level, ferritin, FEP, lead level, bone marrow aspiration? • What about the Mentzer Index? • What about the RDW?

20. Mentzer Index • MCV/RBC • > 13.5 suggestive of iron deficiency • < 11.5 suggestive of thalassemia

21. RDW • Normal value of 11.5 to 14.5 • Elevated value suggestive of iron deficiency

22. White blood cells Hemoglobin Hematocrit Platelets MCV MCH RDW Reticulocyte count Peripheral smear 6.3 8.0 24 675 62 20 18 2.2 normal Lab Results

23. Utilizing the information now available, which of these following diagnoses is most likely the cause of this child’s findings?

24. Microcytic, hypochromic • - Iron Deficiency • Thalassemias • Lead Poisoning • Chronic Inlammation • Inflammatory Bowel Diseases (IBD) • Juvenile Rhumatoid Arthritis (JRA) • Severe Protein Deficiency

25. Therapeutics • What intervention can be both diagnostic and therapeutic for this patient?