Caso studies # 1
Iron-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.
Studies Result Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p. 156
Red blood cell (RBC) count, p. 396 2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399 Mean corpuscular volume (MCV) 72 mm3 (normal: 80–95 mm3 )
Mean corpuscular hemoglobin (MCH) 22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin concentration (MCHC) 21 pg (normal: 27–31 pg)
Red blood cell distribution width (RDW) 9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p. 466 7800/mm3 (normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential Platelet count (thrombocyte count), p. 362 Within normal limits (WNL) (normal: 150,000– 400,000/mm3 )
Half-life of RBC 26–30 days (normal) Liver/spleen ratio, p. 750 1:1 (normal) Spleen/pericardium ratio
Liver/spleen ratio, p. 750 1:1 (normal) Spleen/pericardium ratio
Spleen/pericardium ratio
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+
Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity (TIBC) 500 (normal: 250–420 mcg
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The 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°C, muscle aches, and back pain. The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm3 Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The 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.
Critical Thinking Questions
1. What was the cause of this patient’s iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for the answer.
4. What other questions would you ask to this patient and what would be your rationale for them
Case Studies #2
The 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:
Studies Results
Complete blood cell count (CBC), p. 156
Hemoglobin (Hgb), p. 251 12 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 36% (normal: 42%–52%)
Chest x-ray, p. 956 Right-sided consolidation affecting the posterior lower lung
Bronchoscopy, p. 526 No tumor seen
Lung biopsy, p. 688 Pneumocystis jiroveci pneumonia (PCP)
Stool culture, p. 797 Cryptosporidium muris
Acquired immunodeficiency syndrome (AIDS) serology, p. 265 p24 antigen Positive Enzyme-linked immunosorbent assay (ELISA) Positive Western blot Positive
Lymphocyte immunophenotyping, p. 274 Total CD4 280 (normal: 600–1500 cells/L) CD4% 18% (normal: 60%–75%) CD4/CD8 ratio 0.58 (normal: >1.0)
Human immune deficiency virus (HIV) viral load, p. 265 75,000 copies/mL
Diagnostic Analysis
The 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’s 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.
Critical Thinking Questions
1. What is the relationship between levels of CD4 lymphocytes and the likelihood of clinical complications from AIDS?
2. Why does the United States Public Health Service recommend monitoring CD4 counts every 3–6 months in patients infected with HIV?
3. This patient seems to be unaware of his diagnosis of HIV/AIDS. How would you approach your patient to inform about his diagnosis?
4. Is this a reportable disease in Florida? If yes. What is your responsibility as a provider?
___________________
Case Study #1:
The 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.
Anemia can cause a decrease in oxygen delivery to the heart, leading to angina (chest pain).
Yes, 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.
Other 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.
Case Study #2:
CD4 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.
Monitoring CD4 counts every 3-6 months in patients infected with HIV can help determine the progression of the disease and guide treatment decisions.
When 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.
Yes, 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.

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