Anemia I

Details of this story have been changed. This is about a patient I had on call on medicine wards (which I know I haven't really written about - I'm behind in all the things I want to say). There will be two posts. Today I will introduce the clinical case and ruminate on pre-test probability (one of my favorite topics, I know). Tomorrow, I will discuss an ethical situation I encountered.

An 80 year old woman presents with severe anemia. While a normal hemoglobin might be 12-15 (normal hematocrit 35-45), her hemoglobin was 5 (hematocrit 15). This was one of the lowest I'd ever seen. She presented with shortness of breath and dizziness on exertion as you would expect. She was otherwise completely asymptomatic. If you or I suddenly dropped our hemoglobin to 5, we would be dead. But her anemia had been going on for several years, and her body adapted to it. As an outpatient, she had gotten some blood tests to sort it out: she had an MCV of 81, a low serum iron, high ferritin, low transferrin, low TIBC, poor reticulocytosis. Her peripheral smear showed a bit of everything except schistocytes: she had some polychromasia, anisocytosis, poikilocytosis, ovalocytes, basophilic stippling - nothing too diagnostic. Her vitamin B12 and folate were low-normal. As an outpatient, she had been started on iron and B12 but her anemia continued to worsen; over the course of three years, she dropped her hemoglobin from 12 to 5.

Certainly, if you looked at her numbers, she appeared to have an anemia of chronic disease. However, she simply did not look like someone with a chronic autoimmune disease or indolent infection or cancer. She was active; she played the piano, she walked a mile a day (though more recently, has needed to stop and rest), she worked at a post office. Her past medical history was unremarkable; she had a mastectomy and some high blood pressure. She just took hydrochlorothiazide. She denied drugs and smoking. She occasionally drank alcohol. Overall, she was doing pretty well; she just didn't seem sick.

If you were going to play odds, anemia in an 80 year old is colon cancer until proven otherwise. She had some fecal occult blood tests and 1/3 were positive. She had a sigmoidoscopy over 10 years ago and has been declining colonoscopy since. At each visit with her primary care doctor they discuss the need for colon cancer screening, and each time she politely declines. She's even declined blood transfusions in the past as her symptoms are quite minimal. She just didn't want to go to the hospital.

We admitted her to give her some blood. Easy admission, I thought to myself. (Famous last words). I went to go see her; she was incredibly pleasant and talkative, not short of breath even with that dramatic anemia. Her vital signs were normal. She had a systolic ejection murmur heard throughout the precordium. Otherwise, I thought her initial exam was benign.

I sat down to write my note. It was two or three in the morning. I rubbed my eyes. I got to my problem list: #Anemia, I wrote. When I first started my clinical years, I thought it was weird that doctors would do this "pound" thing.
#Anemia
#Hypertension
#Elevated Creatinine
#FEN
#Dispo
#Code Status
I always thought it was just lazy; wouldn't it look better and be nicer to actually number them? But then I became inculcated into this odd nomenclature and do it myself. I guess new problems pop up and old ones disappear and problems change in priority (which affects the order) and renumbering everything each day is simply a waste of time.

#Anemia, I wrote. What a great internal medicine problem. I decided to actually write a decent note (plus, I had a medical student following me and that prompts me to write better notes to set a good example). I outlined my way of thinking of anemia. I started trying to tease out the cause of her anemia. When I first heard of her, I sort of dismissed it as "probably colon cancer, but we won't find out since she declines colonoscopy." But the more I thought of it, the weirder the case became. She had low platelets for no clear reason and an elevated white blood cell count without evidence of infection. She had a dissociation between her albumin and total protein. Her renal function was worse than I'd expected.

Trying to depuzzle something at 3 in the morning is always a challenge, but I realized she might have something else going on. My suspicion was heightened - even if common things are common, I should at least entertain the idea of a bone marrow problem like myelodysplastic syndrome or even leukemia. And the way I connected kidneys to anemia was with multiple myeloma.

When I went back to examine her in the morning (two hours later), I paid much closer attention to her lymph nodes and abdominal exam. Whoa. I found something. Her spleen was 4 cm below her costal margin (below the ribcage). Normally, I can't feel a spleen at all. Indeed, I had written that her belly examination the night before was "normal." I was a little embarrassed, but you find what you're looking for. When my pre-test probability for an abnormality was a little higher, I convinced myself much quicker that I had an abnormal exam. It also reminded me cursory examinations are not acceptable. More on the workup tomorrow.