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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Identify common causes of anemia

  • Describe common signs and symptoms of anemia

  • Discuss diagnostic evaluation required to determine the etiology of anemia

  • Explain the optimal use of folic acid in patients with macrocytic anemia

  • Recommend a specific treatment regimen for anemia considering the underlying cause and patient-specific variables

  • Develop a plan to monitor the outcomes of anemia pharmacotherapy

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PATIENT PRESENTATION

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Chief Complaint

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"Why am I here? I need to go home now. You can't keep me here."

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History of Present Illness

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Charles Logan is a 68-year-old thin, white male brought to the emergency department by paramedics after being found unconscious on the grounds of a local church. He is now awake, but somewhat confused. He appears to be mildly hypothermic and dehydrated. He is known to the ED medical staff as a homeless veteran with a history of schizophrenia and alcoholism.

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Past Medical History

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Alcoholism × 45 years

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Schizophrenia

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Nonadherent with drug therapy

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Family History

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Unknown

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Social History

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Vietnam veteran. Homeless (long-term). Well known to local social agencies. Sister lives in town; no other family members.

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Tobacco/Alcohol/Substance Use

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Currently smokes 1 to 2 ppd × 50 years. Alcohol—up to two-fifths Southern Comfort per day. No illicit drug use reported.

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Allergies/Intolerances/Adverse Drug Events

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Reports allergies to all antipsychotic medications—"make him lose control of his mind"

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Medications (Current)

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Risperidone 6 mg PO once daily (not adherent)

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Calcium carbonate PRN stomach pain

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Review of Systems

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Hears voices, usually of his mother. Complains of cold extremities and tingling in his hands and feet. Occasional stomach pains that he relieves with calcium carbonate.

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Physical Examination

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General
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Thin, pale white male exhibiting some confusion about whereabouts. A&O × 2, to person and time only

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Vital Signs
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BP 126/76 mm Hg, P 86, RR 18, T 34.4°C (36.6°C after 1 h)

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Weight 135.6 lb (61.6 kg)

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Height 70 in. (178 cm)

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"Fingertips hurt"

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Skin
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Pale, especially extremities. Dry and thickened, showing signs of exposure to winter temperatures. No obvious signs of frostbite

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HEENT
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PERRLA

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Neck and Lymph Nodes
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Normal

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Chest
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Decreased breath sounds. Slight wheezing

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Cardiovascular
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RRR; normal S1, ...

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