Q 1 -2 : The 2 questions are related
Q1:
A15-month-old African American male, who is otherwise healthy, is found to have a hemoglobin level
of 8 g/dL on routine screening. The mean corpuscular volume (MCV) is decreased. His lead screen is within normal limits. You obtain a diet history, which reveals that he drinks about 30–40 oz of whole cow’s milk a day. He eats no meat and some fruits and vegetables. Which of the following is the most likely cause?
(A) sickle cell anemia
(B) thalassemia major
(C) lead poisoning
(D) iron-deficiency anemia
(E) anemia of chronic disease
Q 2:
The most effective next step in management would be to obtain which of the following?
(A) iron studies—serum iron, total iron binding capacity, ferritin
(B) reticulocyte count
(C) hemoglobin electrophoresis
(D) a repeat hemoglobin in 1 month after treatment with folic acid
(E) a repeat hemoglobin in 1 month after treatment with iron
Answer :
Q 1:
(D)
Iron deficiency is the most common cause of microcytic anemia. In children it is often related to excessive consumption of cow’s milk, which is low in iron content, and inadequate consumption of iron-rich foods. Allergy to cow’s milk may also cause occult GI blood losses.
In thalassemia major, there is usually physical evidence of chronic anemia with signs of bone marrow expansion (frontal bossing) and severe anemia often requiring transfusions.
Lead poisoning may cause microcytic anemias; it may also be associated with iron-deficiency anemia, which enhances lead absorption and, therefore, should always be excluded. Anemia of chronic disease (renal disease) may be microcytic or normocytic and should be excluded by history and examination.
Q 2:
(E)
If iron deficiency is strongly suspected, it is reasonable to treat empirically with 3–6 mg/kg/day of elemental iron. An increase in hemoglobin of 1 g/dL within 2–4 weeks confirms the diagnosis.
If laboratory confirmation is necessary because the child is at low risk for iron deficiency, confirmatory iron studies may be obtained. The serum iron is low, the total iron binding capacity high, and the ferritin is low
A reticulocyte count is helpful in hemolytic anemias where it is elevated.
Bone marrow aspirate in iron deficiency is necessary if bone marrow infiltration is suspected (leukemia), but is overinvasive in this situation. Hemoglobin electrophoresis may be done if thalassemia or sickle cell anemia is likely
Answer :
Q 1:
(D)
Iron deficiency is the most common cause of microcytic anemia. In children it is often related to excessive consumption of cow’s milk, which is low in iron content, and inadequate consumption of iron-rich foods. Allergy to cow’s milk may also cause occult GI blood losses.
In thalassemia major, there is usually physical evidence of chronic anemia with signs of bone marrow expansion (frontal bossing) and severe anemia often requiring transfusions.
Lead poisoning may cause microcytic anemias; it may also be associated with iron-deficiency anemia, which enhances lead absorption and, therefore, should always be excluded. Anemia of chronic disease (renal disease) may be microcytic or normocytic and should be excluded by history and examination.
Q 2:
(E)
If iron deficiency is strongly suspected, it is reasonable to treat empirically with 3–6 mg/kg/day of elemental iron. An increase in hemoglobin of 1 g/dL within 2–4 weeks confirms the diagnosis.
If laboratory confirmation is necessary because the child is at low risk for iron deficiency, confirmatory iron studies may be obtained. The serum iron is low, the total iron binding capacity high, and the ferritin is low
A reticulocyte count is helpful in hemolytic anemias where it is elevated.
Bone marrow aspirate in iron deficiency is necessary if bone marrow infiltration is suspected (leukemia), but is overinvasive in this situation. Hemoglobin electrophoresis may be done if thalassemia or sickle cell anemia is likely
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