Patient With Fatigue

Enzo is a 74-year-old male with a history of rheumatoid arthritis (RA) who presents in the clinic with a complaint of fatigue. Enzo is ambulatory with a walker and recently has had intermittent flare-ups of his rheumatoid arthritis (RA) disease activity, with increasing pain and swelling in his affected joints. His energy has been declining over the past few months, so he thought it was a good time to come in for follow-up laboratory testing and reassessment of his medications. Most troublesome, he has fainted twice in the past 2 weeks, which resulted in falls onto his carpeted floor. He is afraid to go out into public and even more afraid to drive his car. He has also had some chest pains with exertion. He is eating and sleeping okay, although he does sleep better if his head is elevated on a few extra pillows. He lives alone and gets meals delivered by a local organization.

Past Medical History
RA for 35 years, affecting hands, feet, knees, hips, and cervical spine
Systolic hypertension
Presbycusis
Medications
Ibuprofen, 600 mg three to four times per day as needed
Methotrexate, 7.5 mg weekly
Atenolol, 25 mg daily
Hydrocodone/acetaminophen, 5 mg/500 mg every 6 hours as needed for pain
Physical Examination
Height: 71 inches; weight: 160 lbs.; BMI: 22.3; blood pressure: 162/60; pulse: 84; respiration rate: 16; temperature: 98.6 °F
Well-developed, well-nourished elderly male in no distress; pale
Lungs: bibasilar rales
Heart: regular rate and rhythm, grade 3/6 systolic murmur, audible S3; positive carotid bruit on the left
Abdomen: no masses, nontender
Rectal: prostate 3+ enlarged, hemoccult negative brown stool
Extremities: marked ulnar deviation of MCP and IP joints in both hands
Labs and Imaging
Hemoglobin: 8.9 g/dL
Mean corpuscular volume (MCV): 80 fL
White blood cell count: 10.7 × 109/L
Platelets: 250,000/L
Reticulocyte count: 0.8%
Ferritin: 415 mcg/L
Electrocardiogram: no acute findings; some evidence of left ventricular hypertrophy
Discussion Questions
1.What is Enzo’s diagnosis?

2.What is the underlying pathophysiology of Enzo’s condition?

3.What is the best therapeutic approach to the treatment of Enzo’s condition?

Sample Solution

Enzo's Clinical Case Analysis

1. What is Enzo's diagnosis?

Based on the provided information, Enzo's primary and most concerning diagnosis is anemia, specifically anemia of chronic disease (ACD) with a likely significant iron deficiency component, exacerbated by chronic gastrointestinal blood loss.

Here's the breakdown of why this diagnosis is supported:

Symptoms: Fatigue, declining energy, chest pains with exertion, and especially the two syncopal episodes (fainting with falls) are classic symptoms of anemia. His elevated head position preference for sleeping also points towards potential cardiac strain from anemia.

Lab Findings:

Hemoglobin: 8.9 g/dL: This is significantly low, confirming anemia (normal range for males typically 13.5-17.5 g/dL).
MCV: 80 fL: This indicates normocytic or mildly microcytic anemia (normal range 80-100 fL). While it's at the lower end of normal, it suggests that red blood cells are not significantly smaller, which can be seen in early iron deficiency or ACD.
Reticulocyte count: 0.8%: This is a low reticulocyte count (normal range usually 0.5-2.5% or 0.8-2.5%). A low reticulocyte count in the presence of anemia indicates that the bone marrow is not adequately producing new red blood cells to compensate for the low hemoglobin. This points towards a problem with red blood cell production rather than excessive destruction or acute blood loss.

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