Anemia in the elderly patient(a geriatrician’s POV)

“Case”: Mrs. RMcGill 66th Family Medicine Refresher

Mon. Nov. 23rd 2015

Workshop A-02 @11h00Workshop C-11 @16h00

Mrs. R, 90yo – Hb 113 g/L• RFC, HPI - Rheum Geri rehab “deconditioning”

– Alone, apt., (I) all basic ADL and most domestic ADL but much more effort (1° fatigue, also unsteady)

– > 2012: “Dragging feet” 4WW– June 2014: Volvulus (R) hemicolectomy

“gen det” (fatigue, weight 150120lbs) walk– Dec 2014: ‘Flu, pneumonia “weaker” walk– Feb 2015: Pseudogout flare Pred walk– March 2015: COPD flare Pred walk– April 2015: Fall “tripped” Geri

• ROS– Mild “sticking” swallowing solids +/- “acid reflux”

PMHx• CAD, HTN, DLP• COPD• OA, pseudogout• Pubic ramus # 2007• L’sp stenosis• Neuropathic pain?

(sciatica?)• PUD - UGIB 2011• Cecal volvulus / (R)

hemicolectomy 2014 (no cancer on path)

• Glaucoma, chronic

P/E• VSS, looks gen well• Fair A/E (B), hyperinfl• No gross LN• OA, no acute inflam• General musc bulk,

some strength prox vibr “stocking” (B)• Unsteady gait• Cog good

Meds• Ramipril 2.5mg DIE• Rosuvastatin 10mg QHS• ASA 80mg DIE• Pantoprazole 40mg QAM• Tiotropium 18μcg 1 inh DIE• Gabapentin 600mg BID• Latanoprost 0.005% 1 gtt OU DIE• Acetaminophen “PRN”

Habits• Ex-cig (quit x20 yrs)• Occasional 1 glass wine (<1/7)• Nil OTC / “natural”

CBC• Hb 113 g/L• MCV 89 fL (N 82-100)• RDW 18 (N 12.7-16)• WBC 5.30 x10-9/L

(N4-11)– Auto diff WNL

• Plt 247 x10-9/L (N 140-450)

Hb trendYear, event Hb (g/L)2007 # 1252009 MI 114902011 UGIB 73102 Tx2013 1156/2014 volvulus

90 post-op

12/2014 ‘flu 1062/2015 gout 974/2015 fall 113

Other labs• Cr 98 μM

– eGFR ~45 mL/min• Ferritin 23.4 μg/L

– 2/2015 (gout): 99.3• CRP 0.83mg/L (N 0-5)

– 2/2015 (gout): 54.49• Vit. B12 288 pM (“N” >133)• Retics 119 x10-9/L (N 20-120)• SPEP (N)• TSH (N)

Mrs. R - Synopsis• (N)cytic anemia: 2° screen

– CBC: (N) MCV & other cell lines, but ↑RDW– Fatigue, weight loss (peri-op)– Nil acute inflammed– Mild UGI Sx (solids dysphagia, GERD)– PNP– Multiple PMHx blood loss likely – Rx iron?– Rx review: ASA (2° prevention), PPI, ?gaba– Other labs: Ferritin ing, mild CKD

• Suspected iron deficiency anemia– R/o UGI pathology (PUD, CA) Referred to GI

GI consult – G’scope 6/2015

• “Friable non-bleeding non-obstructing ulcer at GE junction with irregular margins”– All else (N)

• “Findings consistent with either pill induced ulcer, cardial ulcer or secondary achalasia due to neoplastic changes at the level of the GE junction”– Plan: Increase PPI, re-G’scope 4 wks + Bx

GE junction lesion

GI f/u – 7/2015• “Marked decrease in size of recently

documented ulcer at level of GE junction” - Bx– All else (N)

• Pathology: Poorly differentiated adenoCA• GI referred to Upper GI Surgery clinic (Thoracic)

– Endoscopic submucosal dissection for early esophageal cancer

– Path: “T1b moderately-to-poorly differentiated adenoCA with lymphovascular invasion & a very close deep margin”

– “I do consider this to be a curative endoscopic resection” repeat endoscopy in 3 months…