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Patient centered questions for assessment of "Clinical problem solving and Medical decision making skills (29M)

A 29-year-old-male with a strong family history of stroke and renal failure develops a fever of unknown origin for last three months. He has a history of hypertension. The general examination is found to be cachectic with tachypnoea. He also has a raised jugular venous pulse.  He is also found to have severe normocytic normochromic anemia, hypoalbuminemia, proteinuria, raised creatinine. He is put on regular hemodialysis. His previous chest xray showed a large right sided pleural effusion which on aspiration is found to be hemorrhagic and exudative with lymphocytic pleocytosis with normal pleural fluid ADA and negative CBNAAT. His Echocardiography assessments reveal severe concentric left ventricular hypertrophy LVH with preserved ejection fraction. 

Which of the following is likely responsible for his severe anemia? 

  1. Blood loss during hemodialysis
  2. Chronic inflammation
  3. Folic acid deficiency
  4. Vitamin B12 deficiency
  5. Erythropoietin resistence. 

Which of the following should be checked before starting him on erythropoietin for severe anemia? 
  1. Serum vitamin B12 levels
  2. Peripheral blood smear
  3. Iron deficiency anemia
  4. Serum folic acid levels
  5. Hb electrophoresis 

Which of the following is most likely involved to cause his anemia?

  1. Peritubular capillaries in nephron  
  2. Juxtaglomerular cells
  3. Bone marrow
  4. Macula densa
  5. Messengium

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