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       Case Study # 2

          A 78-year-old female presents to the emergency room after a fall 3 days ago. She recently had a right above-the-knee amputation and was leaning over to pick something up when she fell. She did not want to come to the hospital, but she is having difficulty managing at home because of the pain in her left leg where she fell. Her patient medical history reveals RAKA, peripheral vascular disease, Type 2 diabetes and stage 3 chronic kidney disease. Current medications include quinapril 20 milligrams PO daily, Lantus 30 units at bedtime, and Humalog to scale before meals. There are no known drug allergies. The physical exam is negative, and x-rays reveal no acute injuries. Laboratory studies reveal a normal white blood cell count: Hgb of 8 and HCT 24. The MCV is normal. 

          The first questions I would ask would have to do with the fall. The questions would help to determine if the fall was caused by a blood glucose issue, blood pressure issue or if it was due to her recent surgery. A complete health history, physical examination and a family history is important in determining the correct diagnosis and treatment plan for the patient. The questions listed below ask about her fall history, her diabetes and her hypertension. All these can factor into the cause of her fall.

  • What were you doing just prior to the fall?
  • Where you sitting in a chair/wheelchair and when you reached down did you get dizzy or lightheaded?
  • What time of day did this take place?
  • Had you eaten before the fall?
  • What was your blood glucose, and did you take any insulin?
  • Have you been monitoring your blood pressure at home and if so, can you tell me what they have been since your surgery?

          Family history would include questions about diabetes in her family, who had it if anyone? Does anyone in the family have a history of high blood pressure or peripheral vascular disease? What age did her parents die and what was the cause of their death? What was the cause of her grandparent’s death?

          Primary diagnosis: Anemia of Chronic Disease/Normocystic anemia  

Anemia of chronic disease if common among those in the hospital and is caused by long-standing disease, infections, inflammations and malignancies. The patient in this case study was recently in the hospital for a RAKA and she has chronic kidney disease which is a common cause of anemia of chronic disease. Her CKD is stage 3, and the incidence of this anemia increases with the progression of CKD.  Anemia causes tissue hypoxia which then stimulates erythropoietin production by the kidneys. 90% of the total erythropoietin is produced in the kidneys and as CKD progresses the response to hypoxia decreased which then causes the erythropoietin levels to decrease leading to anemia.

The history and physical if mostly symptoms and signs of anemia. Some common symptoms include; weakness, fatigue, dizziness, near syncope, syncope, exercise intolerance, chest pain and palpitations, anorexia and cognitive impairment in the elderly.

The initial work-up should include:

  • CBC: Hemoglobin, hematocrit, MCV, reticulocyte count index
  • CMP: Renal and liver function tests
  • Iron studies which include serum iron, TIC and ferritin
  • Serum vitamin B12, folic acid, and thyroid-stimulating hormone
  • Stool for occult blood.

Treatment options:

  • Transfusion
  • Treating underlying conditions

Differential diagnosis:

  • Iron deficiency anemia: The body uses iron to make red blood cells. Iron deficiency is a common of anemia in those with CKD. This patient does have CKD and anemia. This diagnosis does fit her presentation in the emergency room. The reason for not using this diagnosis is that she also has diabetes and hypertension. With her recent surgery, the diabetes and the hypertension, this is not the best diagnosis.
  • Myxedema coma: This a result of long-standing, undiagnosed or undertreated hypothyroidism. The cause is usually an infection in the lung or urine infections. Other causes are heart failure, stroke, trauma, surgery and drugs. In this case the patient has just recently had surgery and she does have hypertension. She does not have any reported issues with her thyroid.
  • Adrenal crisis: This is an acute adrenal insufficiency and is life-threatening condition with a mortality rate of 0.5/100 patients /year. Precipitating factors include; infections, trauma, surgery, emotional stress, dehydration, and there are unknown causes as well. This patient did recently have surgery but there is no report of an infection. She also has not reported history of alcohol use, seizures or migraine headaches.

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