Casos clínicos de segunda-feira para discussão em 13.02.2017 - HEMATOLOGIA

Caros,
Iniciando as discussões de segunda-feira, posto as casos de hematologia para discussão com a respectiva divisão.

Atualização: Gabarito está no PDF abaixo. Visualize ou baixe clicando aqui.

Caso 1 (FELIPE E BRENA)

A 46-year-old female with a history of rheumatoid arthritis presents to you with complaints of heavy menses and fatigue. In the past 18 months, her periods have become increasingly heavy for 3–5 days, requiring changing a maxi pad every 1–2 h. She also complains of increasing pain and swelling of her hands and wrists for the past 6 weeks.

On physical exam, there is mild tenderness of the MCP joints, pelvic examination is normal, and she appears pale. Laboratory studies are significant for WBC = 5.2, Hgb = 9.0 g/dL, platelets = 290K, MCV = 76 fL, and RDW = 14. Her erythrocyte sedimentation rate is 32 mm/h. Ferritin is 42.

Which of the following would be the next best diagnostic test in elucidating the primary mechanism of her anemia?

(A) Serum c-reactive protein

(B) Serum iron

(C) Soluble transferrin receptor

(D) Bone marrow iron stores

(E) Reticulocyte count

Caso 2 (SAMUEL E LEANDRO)

A 73-year-old Caucasian male reports for a routine physical examination. Past medical history is significant for hypertension and osteoarthritis, and he is taking metoprolol, naproxen, and a multivitamin. CBC shows a normal WBC and platelets, but hemoglobin 11.8 g/dL and MCV of 106. B12 level is normal.

Which one of the following is the most likely cause of the anemia?

(A) Anemia of chronic disease

(B) Folate deficiency

(C) Renal disease

(D) Alcohol use

(E) Thalassemia trait

Caso 3 (LUCAS E NATHÁLIA)

A 65-year-old male presents to establish medical care after recently moving to your area. He has not been seen by a physician in 5 years. He states that he takes no prescription medications and is generally healthy. He has never smoked. Exam is normal other than obesity. CBC shows a normal WBC and platelets, but hemoglobin is 18.8 g/dL. Repeat hemoglobin 4 weeks later is the same.

What would you recommend as the most appropriate next step in evaluation of his polycythemia?

(A) Erythropoietin levels

(B) Overnight oximetry

(C) CT abdomen

(D) Arterial blood gas

(E) Testosterone level

Caso 4 (IURY, LEONARDO E YUKA)

A 71-year-old female was found to have lymphocytosis on routine CBC. Further workup with flow cytometry revealed stage 0 chronic lymphocytic leukemia. After consultation with the hematologist, she returns to your office and shares that she does not require CLL treatment at this time. 

All of the following are true regarding this patient’s condition EXCEPT?

(A) There is a higher risk of autoimmune cytopenias.

(B) All patients should be up to date with influenza, pneumoccal, and tetanus vaccines.

(C) There is a higher risk of non-hematological cancers compared to the general population.

(D) There is a higher risk of diffuse large B-cell lymphoma.

(E) Prophylactic IVIG should be started due to the higher risk of infection.

Caso 5 (SAMUEL E IARA)

A 34-year-old man is hospitalized after a motorcycle accident. He suffered multiple traumatic injuries, including splenic laceration requiring splenectomy and pneumothorax requiring chest tube placement. Today is post-operative day 7, he is clinically improving, and hopes to be discharged today. Today’s CBC shows the following: WBC = 10.5, hemoglobin = 12.5 g/dL, and platelets = 832 K. Platelet count was normal on the day of admission. 

What is the next best step?

(A) Low dose aspirin and clopidogrel

(B) Peripheral blood smear

(C) Dismiss home

(D) Plateletpheresis

(E) Start heparin therapy

Caso 6 (MISSIELE E FRAN)

A 63-year-old Caucasian female reports for a routine physical examination. Past medical history is significant for hyperlipidemia, morbid obesity, diabetes type II, non-alcoholic steatohepatitis (NASH), hypertension, and osteoarthritis. Medication for the past 3 years have included aspirin, metoprolol, lisinopril, atorvastatin, metformin, and calcium/vitamin D. CBC shows a WBC = 5.8, hemoglobin = 12.8 g/dL and platelets = 85K. 

Which one of the following is the next best step for workup of the thrombocytopenia?

(A) Anti-PF4 antibody

(B) Prothrombin time

(C) Ultrasound of the abdomen

(D) HIV

(E) Peripheral blood smear

Caso 7 (MISSIELE E GUSTAVO)

A 39-year-old African American healthy male presents to you for life insurance screening examination. He takes no medications and has no significant symptoms or past medical history. Physical exam is unremarkable. Laboratory studies show normal chemistries and lipids, but CBC is flagged as abnormal—WBC is 2.1 with a low absolute neutrophil count (ANC) of 1350. Hemoglobin and platelets are within normal range.

What is the most likely cause of the neutropenia?

(A) Lupus

(B) Lead exposure

(C) Benign ethnic neutropenia

(D) Herbal medications

(E) Epstein–Barr virus

Case 8 (LUCAS E RENATA)

A 63-year-old Caucasian female reports for a routine physical examination. Chemistry laboratories are significant for an elevated total protein, which leads to further testing. Serum protein electrophoresis shows an M-spike of 3.0 g/dL which is IgM kappa on immunofixation. Free light chains (FLC) are 232 kappa and 1.8 lambda with a FLC ratio of 128,9. CBC, creatinine, calcium, and bone survey are normal.

You give her the following diagnosis:

(A) Monoclonal gammopathy of undetermined significance

(B) Multiple myeloma

(C) AL amyloidosis

(D) Smoldering multiple myeloma

(E) Waldenstrom’s macroglobulenemia