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PA13.{2,4} | Approach to Anemia & Lab Investigation — Case Study Workup
CLINICAL SCENARIO
A 45-year-old schoolteacher from Tamil Nadu presents with fatigue and breathlessness. Work through this real-world clinical scenario to apply your understanding of anemia classification, CBC interpretation, targeted investigation, differential diagnosis, and management — the complete workup cycle you will perform as a clinician.
Instructions
Read the case scenario carefully before beginning. Answer each section in order — later sections build on your earlier reasoning. Aim for 1800–2200 words total across all sections. Submit as a single PDF or Word document with section headings clearly marked. Peer review will open 24 hours after submission closes and must be completed within 48 hours. Your reviewer will use the same rubric criteria to give you structured feedback.
Length: 1800–2200 words total. Balance depth across all six sections. Section 2 and Section 4 typically require the most detail.
What to Submit
Section 1: Initial Clinical Assessment
Section 2: CBC Interpretation
Section 3: Targeted Investigations
Section 4: Differential Diagnosis Exclusion
Section 5: Find-the-Cause Workup
Section 6: Management Plan
Grading Rubric — Approach to Anemia — Case Study Workup Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Accuracy and depth of pre-investigation clinical reasoning: correct identification of anaemia category from symptoms and signs, interpretation of koilonychia/glossitis/angular cheilosis as IDA stigmata, identification of specific risk factors (menorrhagia + vegetarian diet). | 5 pts | All three clinical signs correctly interpreted with their pathophysiological basis. Category of anaemia correctly identified with full justification. Both risk factors identified and their mechanism explained. |
| Systematic interpretation of each CBC parameter, accurate MCH calculation, correct dual classification (morphological + RPI-based), and appropriate peripheral smear correlation. | 5 pts | All CBC parameters interpreted correctly with clinical significance. MCH calculated correctly (24.4 pg). RPI calculated correctly (~0.27, confirming hypoproliferative). Classification correct on both frameworks. Smear findings (pencil cells, target cells, anisocytosis) correlated with CBC. |
| Rational selection of iron studies panel; correct prediction of expected results in IDA; identification of most specific test; recognition of ferritin limitations in inflammation. | 5 pts | All five iron studies listed with expected results in IDA (low serum iron, low ferritin, high TIBC, low transferrin saturation ≤15%). Bone marrow iron stores identified as the gold standard. Ferritin as acute-phase reactant noted; CRP/ESR suggested as adjunct. All justifications present. |
| Quality of systematic exclusion of thalassaemia trait, ACD, sideroblastic anaemia, and lead poisoning using clinical + investigative reasoning. Accuracy of comparison table. | 5 pts | All four differentials addressed with correct reasoning. Thalassaemia trait correctly distinguished (normal/low RDW, target cells, HbA2 on HPLC as distinguishing test). ACD correctly characterised (low TIBC, normal/high ferritin). Sideroblastic and lead poisoning correctly handled. Comparison table accurate on all parameters. |
| Ability to identify multi-factorial aetiology, formulate targeted history for menorrhagia, outline appropriate referral/investigation pathway, and apply clinical judgement on bone marrow indication. | 5 pts | Both causes (menorrhagia + inadequate dietary iron) identified as contributing factors. At least 5 specific history items for menorrhagia listed. Gynaecology referral with appropriate investigations stated. OGD indication correctly limited to non-response to iron after gynae cause confirmed. Bone marrow indication correctly stated as not required here. |
| Specificity and completeness of pharmacological prescription, dietary counselling, monitoring timeline, parenteral iron indications, and non-response workup. | 5 pts | Oral iron prescribed with correct salt (ferrous sulphate 200 mg or equivalent elemental iron 60 mg), frequency (BD/TDS), timing (empty stomach or 1 hr before meals), and duration (3–6 months post-correction). Three vegetarian iron sources and two absorption inhibitors named. Reticulocyte rise at 5–10 days stated. Hb rise 1–2 g/dL per month stated. Three specific parenteral iron indications given. Three non-response causes listed with next steps. |
PEER REVIEW
As a peer reviewer, your role is to provide constructive, evidence-based feedback using the following focus areas:
- Investigation justification: Did the author clearly explain WHY each test was ordered — not just list tests? Could you follow their diagnostic reasoning?
- Differential reasoning depth: Were the four differentials (thalassaemia trait, ACD, sideroblastic, lead) addressed with specific distinguishing features, or were they dismissed vaguely? Was the comparison table accurate?
- Management specificity: Did the author give a complete prescription (drug, dose, frequency, timing, duration)? Was the monitoring plan tied to expected physiological milestones (reticulocyte peak, Hb rise rate)? Was the management plan specific enough that a junior nurse could implement it, or was it too vague?
Provide:
- One strength: What did the author do particularly well? Be specific (e.g., 'The RPI calculation was correctly performed and interpreted').
- One area for improvement: Be specific and constructive (e.g., 'The management plan prescribes iron but does not specify timing relative to meals or mention absorption enhancers').
Review tone: collegial, educational. The goal is learning, not marking.