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
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bone marrow biopsy
B
c
b) Vitamin B12 and Folate levels
C
e) Ct Scan abdomen to see retro peritoneal bleeding
a DCT
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
E
B:) B12 and folate level. Warfarin is associated with B12 deficiency.
a
nice qt
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.
Answer B. The patient presented with severe fatigue and exertional shortness of breath. There is no other history of gross bleeding. Physical examination is normal. MCV is 102.