Patient's Query
Hello doctor,
I am seeking your expert opinion regarding a series of concerning health issues of my mother over the past two years. I have compiled her blood test results over the last year, along with relevant information such as age, weight, and other clinical details, in an attached spreadsheet for clarity.
The key areas of concern include:
Weight and muscle loss: A significant reduction of approximately 6 kg (14 lbs) and noticeable muscle loss in the arms over the last two years.
Haematological findings: Persistently low lymphocyte and platelet counts.
Cardiac health: Severe atrial fibrillation, managed with Warfarin and Atenolol, raising concerns about cardiac function.
Nutritional concerns: A recent history of Vitamin D deficiency that has been treated but raises concerns about ongoing vitamin insufficiency.
Bone health: Osteopenia without progression to osteoporosis.
I would greatly appreciate a detailed and technical evaluation of her haematological status and your insight into whether any underlying cardiac issues may be contributing to her clinical picture.
Please let me know if you require any further information. The attached spreadsheet contains all relevant data for your review.
Thank you.
Hi,
Welcome to icliniq.com.
I read your query and can understand your concern.
Hereby I am giving you my opinion regarding your mother's health condition. (attachment removed for patient identity protection)Vitamin D levels are very low here, which can lead to pathological fractures and pain also. For that vitamin D sachet or tablet, it can be prescribed. Sachet contains 50000 IU, and tablet contains 5000 IU dose. Sachet taken once a week and tablet taken daily for six to eight weeks duration.
In atrial fibrillation there are chances of the development of systemic thrombosis; that is why you have been prescribed warfarin therapy, and you should continue it.
For decreasing fibrillation and as cardioprotective, you have been prescribed atenolol, which is the correct drug (beta blocker).
For low lymphocytes, rule out HIV by ELISA (enzyme-linked immunosorbent assay) fourth-generation test.
If HIV negative, other chronic infections like tuberculosis are ruled out by sputum examination and chest X-ray if needed.
Bone marrow suppression can also lead to low lymphocytes.
An autoimmune disorder panel can be investigated if needed.
Clinical correlation is needed in your case.
Consult a nearby hematologist for examination, especially liver, spleen, and lymph node palpation, and accordingly further work up as per need.
I hope I have answered your query.
Let me know if I can assist you further.
Thank you.
Patient's Query
Hello doctor,
Thank you for your guidance and the information provided.
I appreciate your advice that further workup is necessary. I will try to locate a nearby haematologist to consult, although it is proving to be a challenge.
To provide additional context:
Additionally, I realized that I did not mention the issue of muscle wastage in my initial correspondence. This has been a notable concern, and I would greatly value your insights on this matter.
Thank you once again for your time and support.
Hello,
Welcome back to the icliniq.com.
If tuberculosis signs not present and sputum examination and chest X-ray negative than no need for further work up for tuberculosis. You can consult nearby physician if hematologist not available for examination and getting prescription of vitamin D as vitamin D deficiency present.
I hope I have answered your query.
Let me know if I can assist you further.
Thank you.
Patient's Query
Hello doctor,
Thank you for your guidance.
My mother is currently taking vitamin D, which, as you identified, is very important. Upon reviewing her blood cell results over time, I have concerns that she may have a form of macrocytic anemia potentially linked to an underlying lymphoma. I would greatly value your expert opinion on this.
Thank you once again for your time and expertise.
Hello,
Welcome back to icliniq.com.
In lymphoma usually splenomegaly, lymphedenopathy or liver enlargement present. For that clinical examination can be done in right hypochondrium and left hypochondrium and cervical node palpation.
In lymphoma count can be high if it is CLL (chronic lymphocytic leukemia). So possibility of lymphoma is less. But still for safer side liver, spleen, lymph nodes palpation should be done.
Thank you.
Patient's Query
Hello doctor,
Thank you for your thorough and helpful guidance. I greatly appreciate the time and attention you have given to this case.
I will arrange for my mother to have another physical examination as soon as possible.
Thank you once again.
Hello,
Welcome back to the icliniq.com.
I will be happy to solve your query in future if needed.
Good luck.
Take care.
Patient's Query
Hello doctor,
My mother has recently experienced an ischaemic stroke. She is currently taking Warfarin (5 mg), Bisoprolol, Ramipril, and Furosemide. Despite being on Warfarin, her INR is 1.7, which is outside the therapeutic range. She weighs 90.38 pounds and is 76 years old. Her physician has suggested a change in anticoagulant therapy.
I would greatly appreciate your expert advice, considering her age, weight, and the most current research, on whether Apixaban or Dabigatran would be the most appropriate option for her.
Additionally, could you advise on the optimal dosing regimen and the reasoning behind your recommendation?
Thank you.
Hello,
Welcome back to icliniq.com.
Hereby I will give my opinion regarding your query.
You are right today instead of Warfarin newer drugs used as anticoagulant in atrial fibrillation and as prophylactic anticoagulants that is.
Rivaroxaban.
Apixaban.
From these two drug any drug can be prescribed.
Rivaroxaban is selective factor XA inhibitor and rapid onset of action. It does not require regular blood testing and any food can be taken like green leafy vegetables (in comparison to warfarin). Dose is 20 mg OD in atrial fibrillation. You can Consult your haematologist and accordingly get prescription of Rivaroxaban. But this drug is costly as compare to Warfarin that is the fact.
I hope I have answered your query.
Let me know if I can assist you further.
Thank you.
Patient's Query
Hello doctor,
Thank you for your answer.
We are considering either Dabigatran or Apixaban as the next anticoagulant for my mother, following her ischaemic stroke. I would greatly appreciate your expert advice on which of these would be the most appropriate choice and the reasons behind that recommendation.
Please note that cost is not a factor. Your previous response did not specifically address this decision, so I would be grateful for further clarification.
Thank you for your time and guidance.
Hello,
Welcome back to the icliniq.com.
I will guide you further for your mother condition do not worry.
Sorry I had not mentioned any comment on Dabigatran. Dabigatran and Apixaban both are called as non vitamin k antagonist oral anti-coagulant. Both these drug equally effective and effectiveness is of no issue and can be definitely preferred over Warfarin. But if one drug has to choose than I will prefer Apixaban over Dabigatran. Apixaban is equally effective and having less chance of bleeding complication as compare to Dabigatran (this is because Apixaban is factor XA inhibitor and Dabigatran is a thrombin inhibitor). So I prefer Apixaban if you want to choose a drug of choice from these two. Dose is 5 mg BD.
You can consult your haematologist for examination and can get a prescription of this drug.
I hope I have answered your query.
Let me know if I can assist you further.
Thank you.
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Answered byDr. Goswami Parth Rajendragiri
Medically reviewed byiCliniq medical review team
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