A 50-year-old diesel mechanic with recurring nosebleeds, fatigue, and weight loss

A 50-year-old man is prompted to visit your office because of a nosebleed that has been recurring for 2 days. He says that this is the third episode of nosebleeds in the last 6 months. He expresses concern that he becomes easily fatigued at work, and 2 months ago he began noticing bruises on his arms and legs, although he does not recall the causes. He has lost more than 12 pounds in the last 2 years, which he attributes to loss of appetite.

History of previous illness includes a fractured arm in childhood. He has had three bad colds in the past 2 years that lasted for more than a week and included coughing and breathing difficulty. The patient occasionally drinks beer; he quit smoking cigarettes 4 years ago. He does not have allergies and is taking no medications at this time.

On examination, you find a muscular man with somewhat pale and dry skin. Conjunctivae are pale. Numerous ecchymoses and petechiae are noted on arms and legs. Many seem to be old with incomplete healing. BP is 138/84; HR is 94. Temperature is normal. His throat is moderately inflamed, and prominent cervical nodes are palpable. Examination is otherwise within normal limits.

On further questioning, you learn that the patient is a diesel mechanic and has worked on trucks for the same employer for the previous 12 years. He and his wife divorced 8 years ago; his wife became nervous and withdrawn after two miscarriages, which led to marital stress. He has lived in his home for the past 16 years. He has a daughter, age 16, who lives with his ex-wife.

Laboratory studies reveal the following: glucose, BUN, and bilirubin within normal limits; Hgb 10.2 g/dL (normal 14.0–18.0); Hct 32.6% (44.8–52.0); RBC 3.32 mil/mm³ (4.3–6.0); MCV 98 fl (80–100); MCH 31 pg (26–31); MCHC 31% (31–36); WBC 1500 mm³ (5000–10,000); segs 60% (40–60); bands 1% (0–5); lymphs 31% (20–40); monos 8% (4–8); platelets 50,000/mm³ (150,000–400,000). A chest X ray is negative except for some suggestion of hyperlucency; EGG is normal.

(a) What is the problem list for this patient? What is the differential diagnosis?

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(b) What additional testing would you recommend?

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(c) What measures would you take to manage the case and treat this patient?

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Answers to the Pretest can be found in Challenge answers (3) through (7) on pages 17 and 18.