The stem
A 71-year-old man is referred with tiredness and breathlessness on exertion. He has not noticed any bleeding. There is a vague mass in the right iliac fossa.
Laboratory reportSpecimen: blood
| Test | Result | Units | Reference |
|---|---|---|---|
| Haemoglobin | 8.1 L | g/dL | 13.5 – 17.5 |
| MCV | 69 L | fL | 80 – 100 |
| MCH | 21 L | pg | 27 – 33 |
| White cell count | 7.4 | ×109/L | 4.0 – 11.0 |
| Platelets | 465 H | ×109/L | 150 – 400 |
| Ferritin | 7 L | ng/mL | 30 – 400 |
Typical adult reference ranges. Always read results against your own laboratory’s ranges.
The examiner’s questions
Question 1Describe the blood count.Show the model answer
A microcytic, hypochromic anaemia (low haemoglobin, MCV and MCH) with a very low ferritin: iron deficiency anaemia. The raised platelet count is reactive.
Question 2What is the most likely cause in this patient?Show the model answer
Chronic blood loss from the gut. In an older man with iron deficiency and a right iliac fossa mass, cancer of the caecum or ascending colon is the most likely cause. Right-sided cancers bleed slowly without visible blood.
Question 3How would you investigate?Show the model answer
Colonoscopy and upper endoscopy, because the source can be in either; coeliac serology; and CT to stage if a tumour is found.
Question 4Does he need a blood transfusion?Show the model answer
Not routinely. He is stable, and the anaemia has developed slowly. Iron replacement, intravenous if surgery is planned soon, is preferred. Transfusion is for instability, severe symptoms or active bleeding.
After you answerThe teaching pointShow
Iron deficiency anaemia in a man, or in a woman after the menopause, is gastrointestinal blood loss until the gut has been examined.
The patients and results are written for teaching and do not belong to real patients.