50 year old male complains of weakness and exertional shortness of breath. He de

Question

50 year old male complains of weakness and exertional shortness of breath. He denies any chest pain. He golfs twice a week and runs two miles every other day but the runs have been cut short secondary to his presenting symptoms. Vtal signs: BP=130/70mmHg,HR=98, RR=18. Physical exam is significant for pallor and a soft systolic murmur. Chest is clear to auscultation and there is no evidence of lower extremities edema.(Hint:shortness of breath in the absence of heart and lung pathilogies-think hematology.)
Which test would you order? why?
The patient returns four weeks later. Laboratory values are significant for a hemoglobin and hematocrit( H&H) of 10/32, reticular index of 2, low iron, and high total iron binding capacity (TIBC). What is the most appropriate next step in management?
What is the most likely cause for this patient's anemia?

Explanation / Answer

soft systolic murmur without evidence of heart failure, normal BP with high HR and RR indicates that the heart is trying to move more oxygen out of the lungs to the tissues. you should be thinking of anemia. the murmur can be due to a decreased red cell mass causing decreased viscosity, which increases reynold's number and can change laminar fluid flow to turbulent fluid flow, causing an audible sound. to evaluate for anemia, first we order a CBC, a reticulocyte count (tells us if the marrow is responding appropriately to anemia) and iron studies. his CBC shows anemia (low H&H) with a good reticulocyte response, indicating that we dont have to worry about somethign that affects RBC formation in the marrow like sickle cell or thalassemia. however the iron is low and TIBC is high, suggesting there may be an iron deficiency anemia, so the next step would be iron supplementation therapy. because iron-deficiency anemia is rare in men, we have to wonder why he's losing iron all of a sudden. the most worrisome thing would be occult loss of blood, for example, in the stool. this should make you suspicious for possible colon cancer, so we should probably send this guy for a colonoscopy, especially since he's 50 and its time he got screened. hope that helps! jonathan

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