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  #1  
Old 07-27-2013
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Blood Megaloblastic Anemia Question

A 23yr old man presents with complains of light-headedness, fatigue n confusion.1 year history of seizures treated with phenytoin. his last seizure was 6 months ago, drinks 2-3 beers on weekend doesnt smoke.
vitals:
temp..99.5f
rr 12/min
bp 130/90 mmhg
pulse 90/min

labs:
hb 9.2
platelets 200,000
wbc 4,000
mcv 105
mchc 35%
mch 33.6
plasma homocysteine increased
methylmalonic acid normal

most appropriate next step?

a) discontinue phenytoin
b) administer folic acid replacement
c) measure vit b12
d) measure folic acid
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Old 07-27-2013
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B give folic acid
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Old 07-27-2013
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Quote:
Originally Posted by drsrb View Post
A 23yr old man presents with complains of light-headedness, fatigue n confusion.1 year history of seizures treated with phenytoin. his last seizure was 6 months ago, drinks 2-3 beers on weekend doesnt smoke.
vitals:
temp..99.5f
rr 12/min
bp 130/90 mmhg
pulse 90/min

labs:
hb 9.2
platelets 200,000
wbc 4,000
mcv 105
mchc 35%
mch 33.6
plasma homocysteine increased
methylmalonic acid normal

most appropriate next step?

a) discontinue phenytoin
b) administer folic acid replacement
c) measure vit b12
d) measure folic acid
c) i would measure vit b12
Defficiency of which could cause of CNS problems and increased homocysteine
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Originally Posted by MedicalExaminer View Post
c) i would measure vit b12
Defficiency of which could cause of CNS problems and increased homocysteine
MMA is normal = b12 level is normal no need to measure it.

my answer would be B)
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Old 07-27-2013
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yea even i went with b...folic acid replacement..but the answer given was folic acid measurement so i was confused...coz from d labs its obvious the guy is low on folic acid...rather than wasting more time on testing it wud b apt to replace folic acid!!
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Quote:
Originally Posted by drsrb View Post
yea even i went with b...folic acid replacement..but the answer given was folic acid measurement so i was confused...coz from d labs its obvious the guy is low on folic acid...rather than wasting more time on testing it wud b apt to replace folic acid!!
then probably they mean that you first must diagnose it , and then treat it.
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Old 07-27-2013
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but the question was most apt step?
dx or treat?
coz the dx is obvious from the labs!!
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Quote:
Originally Posted by drsrb View Post
but the question was most apt step?
dx or treat?
coz the dx is obvious from the labs!!
Now in retrospect i would go for Dx first and then treat.

Only diseases where u treat first , is usually in very acute situations - appendicitis going to appendectomy if pts is septic ,
Corticosteroids when spinal cord compression before any imaging , etc etc etc
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Old 07-30-2013
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why not discontinue the phenytoin and switch to another antiepileptic?
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Old 07-30-2013
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and guys, i came across a similar question yesterday.

guy comes in to ER for a seizure. he's an alcoholic. he has a history of seizures and takes phenytoin on and off. they give lab values and you see MCV is high and HB/Hct is low. they ask what is the cause of his hemotologic symptoms?

deficiency of:
a) folic acid
b) b12
c) thiamine
d) b6
e) vitamin C

(how can i differentiate between folic acid and b12? simply because he's on phenytoin and that decreases absorption of folic acid?)
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Old 07-31-2013
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Originally Posted by Dr.NickRiviera View Post
and guys, i came across a similar question yesterday.

guy comes in to ER for a seizure. he's an alcoholic. he has a history of seizures and takes phenytoin on and off. they give lab values and you see MCV is high and HB/Hct is low. they ask what is the cause of his hemotologic symptoms?

deficiency of:
a) folic acid
b) b12
c) thiamine
d) b6
e) vitamin C

(how can i differentiate between folic acid and b12? simply because he's on phenytoin and that decreases absorption of folic acid?)
yeah thats one clue and + he is alcoholic
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Here is a very fine line in these alcoholics - if they drink liquor - they become deficient in folate (faster than B12 and very fast with phenytoin)

If the alcoholic drinks 6 pack of beer every day - he is not likely to be deficient in folate.

Beer has a lot of folate (unless he is not on phenytoin)

All the quality questions on this (like UW) usually use Wine in a q stem.
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