F.A. is an 80 yr. man who presents to the VeteransAdministration Hospital for a routine checkup. Upon questioning, hestates that he “has been feeling weak and terrible” for nearly sixmonths now but has not experienced any loss in weight. W.L. says“I’ve been feeling really lousy lately. I have no energy whatsoeverand I’m always cranky.” Previous Medical History: • Multiple DVTwith chronic venous insufficiency • Type 2 DM • HTN •Hyperlipidemia • Prostate cancer S/P prostatectomy • S/P CVA • DJD;hip fracture 7 years ago; chronic pain in lower back and rightbuttock • Mild memory loss • Chronic allergic rhinitis • Seizuredisorder for 17 years; no seizures with phenytoin (100 mg) in 3years • COPD for 11 years Further assessment of the patientreveals: • Retired at age 62 after 42 years as a coal miner •Long-term history of cigarette use, which continues at 10cigarettes/day • Heavy EtOH use (mostly beer) on and off for 15years, which continues • Very little physical activity Vital Signs_BP= 130/85, Resp. Rate =18bpm, BMI= 28.1, Pulse=110bpm,Temp=97.8*F, arterial O2 sat.=95.5% Decreased breathing soundsbilaterally with diffuse inspiratory and expiratory wheezesbilaterally. Normal thyroid. Patient has some difficulty focusing.Also, pallor is prominent on skin and oral mucosa, slightly noticedin conjunctiva. Intact vibratory sensation. Negative for thefollowing: headache, swelling of ankles, chest pain, anorexia, soremouth/tongue, lightheadness, pain with swallowing, muscle/abdominalpain, diarrhea, bruising or bleeding, bruits, jaundice, glossitis,SOB (shortness of breath), JVD (jugular venous distension),lymphadenopathy, bruits, splenomegaly, hepatomegaly, paresthesias,clubbing, cyanosis, and ataxia. Various Laboratory Blood TestResults: Electrolytes (Na,K,Cl,HCO3, Ca, Mg) all normal Kidneyfunction tests: BUN =high normal, Cr= normal LDL=99 mg/dL,HDL=30mg/dL, Cholesterol= 194 mg/dL Liver function tests : AST,ALT, Alk phos= normal; Bilirubin= high normal, Albumin= low normalFasting Glucose= 185 mg/dL Hb=8.8 g/dL Hct= 19.7% RBC=3,000,000/mm3 WBC= 4,400/mm3 Plt= 139,000/mm3 MCV= 103 fL MCHC=33.5g/dL Fe= 67 microgram/dL TIBC = 312 microgram/dL Transferrinsaturation= 39% Ferritin= 124 ng/ml Vitamin B12=230 picogram/mLFolate= 1.7 ng/mL HbA1c= 9.3% TSH= 3.97microUnits/mL (normal)Peripheral Blood Smear: • Anisocytosis + poikilocytosis • Largeneutrophils with 6–7 segments • Macrocytic, normochromic RBCs
8. What risks does F.A. have that made him susceptible to thistype of anemia?
9. Draw or describe the size and shape of the RBC’s in this typeof anemia based on information given in the blood test results.
10. Identify the test results (signs) that are consistent withthe OTHER previous diagnoses, being sure to identify which signgoes with each diagnosis. Identify the signs of previous diagnosesthat overlap with signs of F.A.’s type of anemia, if there areany.
11. What is the significance of the absence of paresthesias andataxia and the presence of intact vibratory sensation?
12. What treatment and life-style changes would you recommend toF.A.?
