A 70-year-old woman presented with progressive weakness and fatigue. The symptoms had begun about a month earlier, and she no longer
She had no history of recent bleeding, jaundice, fever, anemia, or heart disease. She had not been exposed to medications (other than occasional vitamins and aspirin) or toxins. She had not abused alcohol and had no previous hospitalizations. Findings on the physical examination were unremarkable except for mild tachycardia at rest (96 bpm), a blood pressure of 146/84 mm Hg recumbent and 142/78 mm Hg standing, pallor, external hemorrhoids, and trace pitting edema of the feet. Neither the liver nor spleen were palpable. The stool was negative for occult blood.
A chest x-ray was normal, and an electrocardiogram showed only sinus tachycardia. The blood urea nitrogen (BUN) level was 15 mg/dL; glucose, 108 mg/dL; and total bilirubin, 1.2 mg/dL (normal, <1.2). Electrolyte levels were normal. A sickle cell preparation was negative.
Orders were written to monitor vital signs, transfuse three units of packed red blood cells during the night, and arrange for a bone marrow aspiration and biopsy in the morning.
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