Case 78 – the Beginning

A 72 year old lady has attended pre- assessment clinic for an elective hip replacement and had routine bloods taken.

Blood results:

Hb 93, MCV 97, Plt 220, Wcc 7.5,  Neu 0.9, lymph 6.0.

Normal Liver and Renal function 

Blood film report:

“Mild normocytic anaemia with normal red cell morphology. Mild neutropenia, neutrophils are normal in morphology with no dysplastic features. There are some Large atypical lymphocytes, some with prominent granulation. No previous full blood counts available on system. Given anaemia suggest check haematinics. Lymphocytosis may be reactive, particularly in combination with neutropenia please correlate with clinical details, consider repeat sample if results unexpected. Please discuss if persisting as I note this is a pre-op sample.”

You receive a call from the pre-assessment clinic, they tell you that they repeated her blood count and the results were similar. She has recently moved to the area but has had chronic anaemia, with a Hb of around 90 since 2011. She has been noted to have progressive neutropenia since Jan 2016, however the most recent results are the first result when her neutrophils have been less than one. She is not on any regular medications apart from Amlodipine and Co-codamol.

She is due an elective hip replacement as she has a history of Rheumatoid arthritis. Over the last few years she has not required any treatment for her arthritis but she was previously on methotrexate up to 2014.

What further history would you like from the patient?

What would you ask the team to examine for?

What further tests should be undertaken to investigate the chronic anaemia and neutropenia?

Should surgery be delayed while these investigations are performed?

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