Question of the Week # 266

266 )  A 70 year old man is evaluated in the emergency room for severe fatigue and exertional shortness of breath. He was diagnosed with pulmonary embolism 4 months ago and is on Coumadin. He denies any melena or hematochezia. There is no other history of gross bleeding.  On examination, his blood pressure is 100/70 mm Hg and he is afebrile.  Physical examination is normal. Stool for occult blood is negative.  His hemoglobin one month ago was 12gm/dl. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 6.2 g/dL,

Mean cell volume (MCV)  102  fL

Platelet count 170k/µl

Lactic Dehydrogenase 140U/L

Haptoglobin 100U/L

Reticulocyte count 12%

INR : 8.0

Which of the following is the most appropriate next step in managing this patient?

a) Direct Coombs Test

b) Vitamin B12 and Folate levels

c)  Bonemarrow biopsy

d) Start Corticosteroids

e) CT scan of the Abdomen

14 Responses

  1. bone marrow biopsy

  2. B

  3. c

  4. b) Vitamin B12 and Folate levels

  5. C

  6. e) Ct Scan abdomen to see retro peritoneal bleeding

  7. a DCT

  8. e) CT scan of the Abdomen

    drop of HB
    INR=8
    normal HDL and Haptoglobin
    so, its not hemolysis
    do CT scan to ruleout hemorrhage

  9. E

  10. B:) B12 and folate level. Warfarin is associated with B12 deficiency.

  11. a

  12. nice qt

  13. what’s the answer for this question ?

    • E. INR is high and haptoglobin/LDH WNL= check for internal bleeding. Reticulocyte count elevated so hematopoiesis not compromised – BM biopsy not required.

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