Caso studies # 1
\nIron-Deficiency Anemia Case Study A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on stopping his activity. He has no history of heart or lung disease. His physical examination was normal except for notable pallor.
\nStudies Result Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
\nChest x-ray study, p. 956 No active disease
\nComplete blood count (CBC), p. 156
\nRed blood cell (RBC) count, p. 396 2.1 million\/mm (normal: 4.7\u20136.1 million\/mm)
\nRBC indices, p. 399 Mean corpuscular volume (MCV) 72 mm3 (normal: 80\u201395 mm3 )
\nMean corpuscular hemoglobin (MCH) 22 pg (normal: 27\u201331 pg)
\nMean corpuscular hemoglobin concentration (MCHC) 21 pg (normal: 27\u201331 pg)
\nRed blood cell distribution width (RDW) 9% (normal: 11%\u201314.5%)
\nHemoglobin (Hgb), p. 251 5.4 g\/dL (normal: 14\u201318 g\/dL)
\nHematocrit (Hct), p. 248 18% (normal: 42%\u201352%)
\nWhite blood cell (WBC) count, p. 466 7800\/mm3 (normal: 4,500\u201310,000\/mcL)
\nWBC differential count, p. 466 Normal differential Platelet count (thrombocyte count), p. 362 Within normal limits (WNL) (normal: 150,000\u2013 400,000\/mm3 )
\nHalf-life of RBC 26\u201330 days (normal) Liver\/spleen ratio, p. 750 1:1 (normal) Spleen\/pericardium ratio
\nLiver\/spleen ratio, p. 750 1:1 (normal) Spleen\/pericardium ratio
\nSpleen\/pericardium ratio
\nReticulocyte count, p. 407 3.0% (normal: 0.5%\u20132.0%)
\nHaptoglobin, p. 245 122 mg\/dL (normal: 100\u2013150 mg\/dL)
\nBlood typing, p. 114 O+
\nIron level studies, p. 287
\nIron 42 (normal: 65\u2013175 mcg\/dL)
\nTotal iron-binding capacity (TIBC) 500 (normal: 250\u2013420 mcg
\nTransferrin (siderophilin) 200 mg\/dL (normal: 215\u2013365 mg\/dL)
\nTransferrin saturation 15% (normal: 20%\u201350%)
\nFerritin, p. 211 8 ng\/mL (normal: 12\u2013300 ng\/mL)
\nVitamin B12, p. 460 140 pg\/mL (normal: 100\u2013700 pg\/mL)
\nFolic acid, p. 218 12 mg\/mL (normal: 5\u201320 mg\/mL or 14\u201334 mmol\/L)
\nDiagnostic Analysis
\nThe patient was found to be significantly anemic. His angina was related to his anemia. His normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis. His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency. His marrow was inadequate for the degree of anemia because his iron level was reduced. On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of packed RBCs, he developed an elevated temperature to 38.5\u00b0C, muscle aches, and back pain. The transfusion was stopped, and the following studies were performed:
\nStudies Results
\nHgb, p. 251 7.6 g\/dL
\nHct, p. 248 24%
\nDirect Coombs test, p. 157 Positive; agglutination (normal: negative)
\nPlatelet count, p. 362 85,000\/mm3 Platelet antibody, p. 360 Positive (normal: negative)
\nHaptoglobin, p. 245 78 mg\/dL
\nDiagnostic Analysis
\nThe patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the RBC reaction. He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal examination indicated that his stool was positive for occult blood. Colonoscopy indicated right-side colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the surgery well.
\nCritical Thinking Questions
\n1. What was the cause of this patient\u2019s iron-deficiency anemia?
\n2. Explain the relationship between anemia and angina.
\n3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for the answer.
\n4. What other questions would you ask to this patient and what would be your rationale for them
\nCase Studies #2
\nThe patient, a 30-year-old homosexual man, complained of unexplained weight loss, chronic diarrhea, and respiratory congestion during the past 6 months. Physical examination revealed right-sided pneumonitis. The following studies were performed:
\nStudies Results
\nComplete blood cell count (CBC), p. 156
\nHemoglobin (Hgb), p. 251 12 g\/dL (normal: 14\u201318 g\/dL)
\nHematocrit (Hct), p. 248 36% (normal: 42%\u201352%)
\nChest x-ray, p. 956 Right-sided consolidation affecting the posterior lower lung
\nBronchoscopy, p. 526 No tumor seen
\nLung biopsy, p. 688 Pneumocystis jiroveci pneumonia (PCP)
\nStool culture, p. 797 Cryptosporidium muris
\nAcquired immunodeficiency syndrome (AIDS) serology, p. 265 p24 antigen Positive Enzyme-linked immunosorbent assay (ELISA) Positive Western blot Positive
\nLymphocyte immunophenotyping, p. 274 Total CD4 280 (normal: 600\u20131500 cells\/L) CD4% 18% (normal: 60%\u201375%) CD4\/CD8 ratio 0.58 (normal: >1.0)
\nHuman immune deficiency virus (HIV) viral load, p. 265 75,000 copies\/mL
\nDiagnostic Analysis
\nThe detection of Pneumocystis jiroveci pneumonia (PCP) supports the diagnosis of AIDS. PCP is an opportunistic infection occurring only in immunocompromised patients and is the most common infection in persons with AIDS. The patient\u2019s diarrhea was caused by Cryptosporidium muris, an enteric pathogen, which occurs frequently with AIDS and can be identified on a stool culture. The AIDS serology tests made the diagnoses. His viral load is significant, and his prognosis is poor. The patient was hospitalized for a short time for treatment of PCP. Several months after he was discharged, he developed Kaposi sarcoma. He developed psychoneurological problems eventually and died 18 months after the AIDS diagnosis.
\nCritical Thinking Questions
\n1. What is the relationship between levels of CD4 lymphocytes and the likelihood of clinical complications from AIDS?
\n2. Why does the United States Public Health Service recommend monitoring CD4 counts every 3\u20136 months in patients infected with HIV?
\n3. This patient seems to be unaware of his diagnosis of HIV\/AIDS. How would you approach your patient to inform about his diagnosis?
\n4. Is this a reportable disease in Florida? If yes. What is your responsibility as a provider?
\n___________________
\nCase Study #1:
\nThe cause of this patient’s iron-deficiency anemia is likely due to chronic blood loss, as indicated by the positive occult blood in his stool and the subsequent diagnosis of colon cancer.
\nAnemia can cause a decrease in oxygen delivery to the heart, leading to angina (chest pain).
\nYes, it would be recommended to supplement this patient with B12 and folic acid, as they are often deficient in patients with iron-deficiency anemia. B12 and folic acid are necessary for the production of red blood cells and can help improve the patient’s anemia.
\nOther questions that could be asked include the patient’s dietary habits, any recent changes in bowel habits, and any family history of colon cancer. These questions can help determine the cause of the patient’s anemia and guide further diagnostic testing.
\nCase Study #2:
\nCD4 lymphocytes are a type of white blood cell that play a crucial role in the immune system. As HIV attacks and destroys CD4 cells, a decrease in CD4 count is associated with an increased likelihood of clinical complications from AIDS.
\nMonitoring CD4 counts every 3-6 months in patients infected with HIV can help determine the progression of the disease and guide treatment decisions.
\nWhen informing a patient about their diagnosis of HIV\/AIDS, it is important to approach the conversation with sensitivity and empathy. It may be helpful to provide resources and support for the patient, such as counseling or referrals to HIV\/AIDS specialists.
\nYes, HIV\/AIDS is a reportable disease in Florida. As a provider, it is important to report cases of HIV\/AIDS to the appropriate public health authorities to help track and prevent the spread of the disease.<\/p>\n","protected":false},"excerpt":{"rendered":"
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