An 85-Year-Old Woman With Pancytopenia

Robert M. Centor, MD; Marilyn Ligon, MD

Disclosures

August 25, 2006

This series of cases offers an opportunity for you to work through the diagnostic process, determining what tests to order and which questions to ask. A discussion link is provided below to facilitate that process.

Case Summary

An 85-year-old woman went to an urgent care center because she had fallen. She had ecchymoses on her forehead and scalp. She denied previous falls, but admitted that she had felt weak that morning before she fell. The staff at the urgent care center did a brief physical examination and ordered routine laboratory tests. The complete blood cell count (CBC) revealed a pancytopenia, and she was transferred to the hospital.

On review of systems, she complained of recent palpitations. She had noticed some weakness as well, which she blamed on her age. She seemed slightly confused, and a companion confirmed that she had become increasingly confused in the recent past. She apparently had lost weight secondary to a decreased appetite. She denied any change in bowel habits, and specifically had not noticed any blood in her stools.

Past medical history:

Hypertension

Hyperlipidemia

Type 2 diabetes mellitus

Glaucoma

Hypothyroidism

Medications:

Bisoprolol/hydrochlorothiazide (Ziac)

Glipizide (Glucotrol)

Levothyroxine

Social history:

Retired teacher, recently moved from Georgia to Alabama. Strict vegetarian. No smoking, no drinking, no illegal drugs.

Physical exam:

Vital signs: Temperature 98.6°F, pulse 90, respirations 20, blood pressure 118/80 mm Hg

General: No apparent distress, oriented to time and person but not place

Head, eyes, ears, nose, and throat: Pale conjunctiva

Heart: Normal heart sounds; no murmurs, rubs, or gallops

Lungs: Clear

Abdomen: Benign, no organomegaly

Extremities: 2+ edema

Neurologic: Slight decrease in sensation in lower extremities

Initial CBC: Hemoglobin, 5.2; hematocrit, 14.4; white blood cell count, 1.37 (N 42%, L 55%, M 35%); platelets, 41,000.

Question

Develop a differential for causes of pancytopenia in this patient. Although guessing the correct answer may be possible, it is more important that you would request the appropriate tests.

Caveat: I have omitted an important piece of information for didactic purposes. What additional common lab value would you want to know to help you make the diagnosis?

Discussion

Feel free to discuss this case with others. You can monitor or join in the Medscape discussion at http://www.medscape.com/px/discussions/29d59140.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....