Haematology
Case 22: A Patient Who Has Suffered a Collapse
CASE
A 79‐year‐old man is admitted under the medical take with collapse of unknown cause. He has been feeling unwell for some months with increasing fatigue and back pain. The collapse was preceded by feeling faint and dizzy. He lost consciousness for just a few seconds and was well oriented when he regained consciousness. His back pain has been increasingly severe over the last few weeks, requiring opioid analgesia. He has a past history of hypertension, angina, transient ischaemic attacks and high cholesterol. He is an ex‐smoker (having given up 10 years ago) and drinks only occasional alcohol. On examination, he was frail and thin. His BP was 145/90 mmHg and saturations were 96% on air. There was a soft systolic murmur heard over the aortic area which did not radiate. Respiratory examination was normal but on palpation of his abdomen, an enlarged bladder was easily palpable.
Blood tests are as follows:
Hb 8.5 g/dL MCV 85 fL WCC 9.2 × 109/L Platelets 145 × 109/L CRP 10 mg/L Na 132 mmol/L K 3.4 mmol/L Corrected Ca 2.62 mmol/L Urea 25.8 mmol/L Creatinine 350 µmol/L Bilirubin 12 µmol/L ALT 15 U/L ALP 115 U/L Serum iron 8.9 µmol/L Serum ferritin 250 ng/mL Serum folate acid 9.8 nmol/L Serum B12 320 pmol/L
Serum and urine electrophoresis: normal
Chest X‐ray: clear
ECG: normal
QUESTION 1
Your score this session: 0 of 0
At this stage, what is the most likely cause of his anaemia?
Over the next few days his renal function improves after a urinary catheter is inserted, but he again becomes anaemic. Blood results at this time show:
Blood film: leukoerythroblastic with tear drop poikilocytes