Problem
Mr. T.G., age 65, is a well-established patient in your practice. He presents to the office complaining of lightheadedness when he stands up. The patient also states he has had a change in his stool over the past week and with some abdominal cramping. He denies fever, chills, or vomiting. The patient has a medical history of HTN, hyperlipidemia, atrial fibrillation for which he is taking warfarin and arthritis in his right knee, which he controls with an over the counter analgesic. He denies drinking alcohol and quit smoking cigarettes 20 years ago. His physical exam is the following:
• BP: 136/76 HR: 108. RR: 22 T: 98.9 saO2: 98%
• HEENT: pale conjunctiva bilaterally.
• CV: RRR (-) murmurs/bruits/jvd, (+) tachycardia
• Resp: SOB on mild extertion
• Abdomen: Hyperactive BS all quadrants, (-) tenderness on palpation
• Ext: Moves all extremities, (-) edema or swelling, pulses intact
• Neuro: PERLA, mildly off-balance when standing or changing positions
• Skin: Observable pallor
The patient returns to your office the next morning. You review the CBC report with him.
WBC 3.4 (D)
RBC 3.01 (D)
HGB 10.8 (D)
HCT 31.1 (D)
MCV 76.3 (D)
MCH 32.9 (D)
MCHC 29.7 (D)
RDW 19.1 (I)
PLATELET 213 (N)
D= decreased. I= increased N= normal
1. What are the next steps?
2. What additional lab tests do you order?
3. Any consults required?
4. Is this a critical case requiring the ED services today or can this be treated as an outpatient?
5. How do you treat this patient?
6. What type of education do you need to provide?
7. When should he follow up with you?