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Health, Medicine, Nursing
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Case Study
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English (U.S.)
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Common Symptoms of Anemia (Case Study Sample)

Instructions:

A case based discussion ON INTERNAL MEDICINE. a CASE AND DIFFERENT GUIDE QUESTIONS WERE GIVEN TO GUIDE US ON ANSWERING. fIRST AN IMPRESSION OR WHAT WE THINK THE CASE IS ALL ABOUT IS ASKED, THEN THE DIFFERENT SUBJECTIVE AND OBJECTIVE BASES OF OUR ANSWER, THEN THE DIFFERENTIAL DIAGNOSES ON WHAT WE THINK ARE OTHER DISEASE CONDITIONS THAT PRESENT WITH SUCH SYMPTOMS, THEN DIFFERENT DIAGNOSTIC TESTS TO CONFIRM THE DIAGNOSIS, LASTLY, THE TREATMENT AND MANAGEMENT PLAN ON WHAT TO DO TO THE PATIENT.

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Hypoproliferative anemia probably anemia of chronic disease secondary to GI blood loss, probable kidney disease and dehydration, rule out malignancy
1 Subjective bases
Weakness is a common symptom of anemia, there is an inadequate supply of oxygen being delivered to the tissues due to the decrease in the RBCs, however it was not well documented if the patient has been experiencing fatigue and weakness even before the other symptoms occurred. The presence of black stool, or melena is a strong basis of an ongoing bleeding within the patient’s body. Usually, upper gastrointestinal tract bleeding presents with black tarry stool, while in the lower GI, it presents most commonly with a blood-streaked stool, however, there are some instances of LGI bleeding that presents as melena (i.e., slow GI bleeding, or the blood that has been in the GIT for a long time >8 hrs).
It is also a cardinal rule in anemia, that a postmenopausal woman who presents with anemia means that there is a gastrointestinal bleeding until proven otherwise. In this age group, they are vulnerable to infections, and also predisposed to develop comorbid conditions, however, it was only stated that the patient is a known hypertensive and on medication for 10 year. Hypertension indirectly contribute to anemia of inflammation or chronic disease, usually by affecting the kidneys of the patient (Artz, 2019). The patient is also taking amlodipine for maintenance medication, and several studies have also noted that a certain side effect of a long term usage of the medication predisposes the patient to develop gastric ulceration that usually present with black tarry stools.
The presence of other associated symptoms such as diarrhea, nausea and vomiting can all be attributed to the affectation of the GIT, wherein the bleeding stimulated these symptoms.
The patient has also been previously diagnosed with left pelvocaliectasia secondary to obstructive ureterolithiasis and ureteral stenosis, and the latter was managed by placing the stent, however, the stones are being managed by medications. Early in 2009, the development of kidney stones are considered a risk factor for the development of CKD only for patients with rare hereditary conditions, however, a study was published by Rule, et al later that year stating it was found to be a risk factor for the general population. The patient is a long term hypertensive, and the development of such condition greatly predisposes the patient to the development of kidney disease, therefore the erythropoietin production is reduced.
Dehydration may be associated with prolonged water loss thru diarrhea and may be supported by the weakness, tachycardia, and hypotension.
2 Objective bases
On physical examination, the patient presented with pallor, which is a characteristic of anemia due to the decreased RBC in the body insufficient oxygenation of the tissues, the tendency is that the blood will be shunted away from the skin and the extremities, and will supply the vital organs in this case. There was no jaundice or icterae which is significant in ruling out hemolytic causes of anemia.
Orthostatic hypotension was also noted since upon lying down the blood pressure is within the normal range, but upon sitting down, the patient’s blood pressure dropped. This may be due to the blood loss in the GI tract.
The presence of epigastric tenderness on palpation may be due to the underlying pathology behind the suspected GI bleeding of the patient (i.e. ulcer), and the association of left CVA tenderness is most likely due to the ureterolithiasis of the patient and also the probability of kidney disease.
Laboratory examination showed a low reticulocyte production index which is 0.29%, this is less than 2% which means that the most likely cause of anemia is underproduction of RBCs. The MCV is within the normal range therefore it is considered normocytic. Anemia of inflammation or chronic disease presents almost always as normocytic anemia and some cases, microcytic. The Hemoglobin and hematocrit of the patient is also low which are all due to the anemia of the patient.
Differential Diagnosis:
* Iron Deficiency Anemia
* Gastric Cancer
* Potassium Citrate Toxicity
Bases of the Differentials
Iron Deficiency Anemia
Subjective Bases:
A 76-year old woman sought consultation due to diarrhea and weakness. Five days PTC, the patient had episodes of watery diarrhea with noted yellow-colored stools together with nausea, vomiting, poor oral intake, and flank pain. There was a noted change in the stool color from yellow to black four days PTC. There was still watery diarrhea noted amounting to half cup per bout. The patient’s symptoms persisted.
Iron deficiency anemia or IDA is a type of anemia that develops when there are low or insufficient iron body stores to support the production of red blood cells. Iron deficiency happens when there is decreased total iron body content and IDA occurs when there is already diminished erythropoiesis leading to the development of anemia. The cause is IDA is dependent on many factors such as age, gender, and socioeconomic status. The three most common causes of iron deficiency are insufficient iron intake, decreased absorption, and blood loss. In postmenopausal women, the anemia is most often due to blood loss from lesions in the gastrointestinal tract. Losing 4 units of blood either acutely or chronically will lead to complete depletion of body iron stores whereas losing less than 4 units of blood will already initiate depletion of iron stores and affecting erythropoiesis. Any hemorrhagic lesion in the gastrointestinal tract could result in blood loss and iron deficiency. This blood loss could present as melena or hematochezia. The gastrointestinal symptoms of the patient could be attributed to the underlying cause of the bleeding.
Objective Bases:
The physical examination of the patient revealed that she is weak-looking and stretcher-borne. Her vital signs revealed normal heart rate and respiratory rate but there was noted orthostatic hypotension. Additional findings include pale skin, pale palpebral conjunctiva, pale lips, pale nail beds, and pale palmar creases. The abdominal examination of the patient revealed that there were hyperactive bowel sounds, epigastric tenderness, and tympanitic abdomen. The rectal examination revealed black stools.
The patient’s initial CBC revealed low hemoglobin (90 g/L), low hematocrit (0.29 L/L), normal MCV, MCH, and MCHC. The WBC and platelet count were also within the normal range. The reticulocyte production index was low (0.29).
Based on the initial CBC of the patient, there is presence of anemia as evident by the low hemoglobin level. Following the guidelines set by the WHO, postmenopausal women with hemoglobin levels of less than 13 g/dL are diagnosed to have anemia. Taking into account that the WBC and platelet count were within the normal range, the anemia is isolated. The MCV, MCH, and MCHC were also normal suggesting that the patient has hypoproliferative anemia and early iron deficiency anemia is under this category. Patients with IDA are mostly asymptomatic but clinical signs such as pallor can occur when the hemoglobin falls to 8 g/dL.
Gastric Cancer
Subjective Bases:
The patient is a 76 year old woman who was complaining of diarrhea and weakness. The patient recalled that she had 3 episodes of watery diarrhea, with yellow-colored stools and she also experienced nausea, vomiting, poor oral intake, and flank pain five days PTC. She noticed a change in her stool color from yellow to black four days PTC but the stools were still watery and amounting to half a cup per bout. These symptoms persisted. The patient does not smoke and drink alcohol beverages.
Upper gastrointestinal bleeding has several causes and tumor bleeding accounts for 5% of cases. Of these 5%, the most common cause of tumor bleeding accounting for 58% of bleeding cases resulting from upper GI malignancies is primary gastric cancer. Gastric cancer is one of the most commonly diagnosed cancers and is the second most common cause of cancer-related mortality. Its incidence increases with age and the peak occurring at 60 to 80 years. 85% of stomach cancers are adenocarcinomas. In the early stages of the disease, most patients experience nonspecific symptoms. Most specific symptoms would reflect an advanced state of the disease. Patients complain of upper abdominal discomfort, weakness, anorexia, and weight loss. The presence of nausea and vomiting could indicate that the location of the tumor would involve the pylorus. In the diffuse type of gastric cancer, the initial presentation would include abdominal pain and diarrhea. Lesions associated with gastric cancer are frequently ulcerative and in some cases, gastric cancer can cause upper GI bleeding and this is usually mild presenting with signs and symptoms of anemia. Bleeding associated with gastric CA often manifests as hematemesis and melena.
Objective Bases:
Based on the physical examination, the patient is weak-looking and stretcher-borne. The patient has orthostatic hypotension with a blood pressure of 110/80 lying and 90/60 sitting. The skin, palpebral conjunctivae, lips, nail beds, and palmar creases are noted to be pale. Abdominal examination revealed hyperactive bowel sounds with epigastric tenderness. Lastly, the rectal exam showed black stool.
Pertinent findings of the initial CBC of the patient showed low hemoglobin (90 g/L), low hematocrit (0.29 L/L), normal MCV, MCH, and MCHC. WBC and platelet count were all normal. The reticulocyte production index is noted to be low (0.29)....

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