J.D. is a 37 years old white woman who presents to her gynecologist complaining of a 2-month history of intermenstrual bleeding, menorrhagia, increased urinary frequency, mild incontinence, extreme fatigue, and weakness. Her menstrual period occurs every 28 days and lately there have been 6 days of heavy flow and cramping. She denies abdominal distension, back-ache, and constipation. She has not had her usual energy levels since before her last pregnancy.
Past Medical History (PMH):
Upon reviewing her past medical history, the gynecologist notes that her patient is a G5P5with four pregnancies within four years, the last infant having been delivered vaginally four months ago. All five pregnancies were unremarkable and without delivery complications. All infants were born healthy. Patient history also reveals a 3-year history of osteoarthritis in the left knee, probably the result of sustaining significant trauma to her knee in an MVA when she was 9 years old. When asked what OTC medications she is currently taking for her pain and for how long she has been taking them, she reveals that she started taking ibuprofen, three tablets each day, about 2.5 years ago for her left knee. Due to a slowly progressive increase in pain and a loss of adequate relief with three tablets, she doubled the daily dose of ibuprofen. Upon the recommendation from her nurse practitioner and because long-term ibuprofen use can cause peptic ulcers, she began taking OTC omeprazole on a regular basis to prevent gastrointestinal bleeding. Patient history also reveals a 3-year history of HTN for which she is now
Case Study Questions
- Name the contributing factors on J.D that might put her at risk to develop iron deficiency anemia.
- Within the case study, describe the reasons why J.D. might be presenting constipation and or dehydration.
- Why Vitamin B12 and folic acid are important on the erythropoiesis? What abnormalities their deficiency might cause on the red blood cells?
- The gynecologist is suspecting that J.D. might be experiencing iron deficiency anemia.
In order to support the diagnosis, list and describe the clinical symptoms that J.D. might have positive for Iron deficiency anemia.
- If the patient is diagnosed with iron deficiency anemia, what do you expect to find as signs of this type of anemia? List and describe.
- Labs results came back for the patient. Hb 10.2 g/dL; Hct 30.8%; Ferritin 9 ng/dL; red blood cells are smaller and paler in color than normal. Research list and describe for appropriate recommendations and treatments for J.D.
Cardiovascular
Mr. W.G. is a 53-year-old white man who began to experience chest discomfort while playing tennis with a friend. At first, he attributed his discomfort to the heat and having had a large breakfast. Gradually, however, discomfort intensified to a crushing
sensation in the sternal area and the pain seemed to spread upward into his neck and lower jaw. The nature of the pain did not seem to change with deep breathing. When Mr. G. complained of feeling nauseated and began rubbing his chest, his tennis partner was concerned that his friend was having a heart attack and called 911 on his cell phone. The patient was transported to the ED of the nearest hospital and arrived within 30 minutes of the onset of chest pain. In route to the hospital, the patient was placed on nasal cannula and an IV D5W was started. Mr. G. received aspirin (325 mg po) and 2 mg/IV morphine. He is allergic to meperidine (rash). His pain has eased slightly in the last 15 minutes but is still significant; was 9/10 in severity; now7/10. In the ED, chest pain was not relieved by 3 SL NTG tablets. He denies chills.
Case Study Questions
- For patients at risk of developing coronary artery disease and patients diagnosed with acute myocardial infarct, describe the modifiable and non-modifiable risk factors.
- What would you expect to see on Mr. W.G. EKG and which findings described on the case are compatible with the acute coronary event?
- Having only the opportunity to choose one laboratory test to confirm the acute myocardial infarct, which would be the most specific laboratory test you would choose and why?
- How do you explain that Mr. W.G temperature has increased after his Myocardial Infarct, when that can be observed and for how long? Base your answer on the pathophysiology of the event.
- Explain to Mr. W.G. why he was experiencing pain during his Myocardial Infarct. Elaborate and support your answer.
Full Answer Section
4. Clinical Symptoms of Iron Deficiency Anemia in J.D.:
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Intermenstrual Bleeding: A hallmark symptom of iron deficiency anemia, especially when combined with heavy menstrual flow.
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Fatigue and Weakness: Common manifestations of iron deficiency, potentially exacerbated by J.D.'s frequent pregnancies.
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Pallor: Pale skin, especially around the eyes and mouth, is a hallmark of iron deficiency anemia.
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Dyspnea: Shortness of breath on exertion can occur due to reduced oxygen-carrying capacity.
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Headache: Iron deficiency can contribute to headaches, especially during exertion.
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Tachycardia: Increased heart rate, attempting to compensate for reduced oxygen transport.
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Pica: Craving for non-food substances like ice or clay can occur in severe iron deficiency.
5. Expected Signs of Iron Deficiency Anemia:
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Low Hemoglobin (Hb): Hb is the protein in red blood cells that carries oxygen, and it is significantly reduced in iron deficiency anemia.
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Low Hematocrit (Hct): Hct measures the percentage of red blood cells in the blood, which is also decreased in iron deficiency.
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Low Ferritin: Ferritin is a protein that stores iron in the body. Low levels indicate depleted iron stores.
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Microcytic, Hypochromic Red Blood Cells: Iron deficiency anemia leads to small (microcytic) and pale (hypochromic) red blood cells, as seen on a blood smear.
6. Recommendations and Treatments for J.D.:
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Confirm Diagnosis: Further blood tests, including serum iron and total iron binding capacity, can confirm iron deficiency anemia.
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Iron Supplementation: Oral iron supplementation is the first-line treatment.
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Dietary Changes: Increase dietary intake of iron-rich foods like red meat, fish, beans, and leafy green vegetables.
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Vitamin C Supplementation: Vitamin C enhances iron absorption.
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Address Underlying Causes: Investigate and manage the cause of J.D.'s menorrhagia to prevent further iron loss.
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Monitor Progress: Regular blood tests to monitor iron levels and response to treatment.
Cardiovascular Case Study: Mr. W.G.
1. Modifiable and Non-Modifiable Risk Factors for Coronary Artery Disease (CAD):
Modifiable:
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Hypertension: High blood pressure damages blood vessels, contributing to atherosclerosis.
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Hyperlipidemia: Elevated cholesterol levels contribute to plaque formation in arteries.
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Smoking: Damages blood vessel lining, promotes atherosclerosis, and reduces oxygen-carrying capacity.
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Diabetes: Increases the risk of atherosclerosis and other cardiovascular complications.
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Obesity: Contributes to hypertension, hyperlipidemia, and diabetes, increasing the risk of CAD.
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Physical Inactivity: Lack of exercise promotes unhealthy cholesterol levels and weakens the heart.
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Stress: Stress hormones can increase blood pressure and contribute to plaque formation.
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Diet: Unhealthy diet high in saturated and trans fats increases cholesterol levels.
Non-Modifiable:
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Age: Risk of CAD increases with age.
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Gender: Men are at higher risk than women before menopause.
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Genetics: Family history of CAD increases individual risk.
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Ethnicity: Certain ethnicities have higher rates of CAD.
2. Expected EKG Findings and Compatible Findings:
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ST-Segment Elevation: The most classic sign of acute myocardial infarction (MI).
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T-Wave Inversion: May be present in the early stages of MI or in the area of infarction.
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Q Wave: A pathological Q wave is present in the ECG after an MI and indicates necrosis of the myocardium.
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Compatible Findings: Crushing chest pain radiating to the neck and jaw, nausea, diaphoresis, and unrelieved chest pain by nitroglycerin are consistent with an acute coronary event.
3. Most Specific Laboratory Test:
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Troponin I: Highly specific for cardiac muscle injury, increasing rapidly after an MI. It remains elevated for a longer duration than other cardiac markers, allowing for diagnosis even after several hours from the onset of symptoms.
4. Explanation for Increased Temperature:
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Inflammation: Myocardial infarction triggers an inflammatory response, releasing inflammatory mediators that can cause fever.
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Timing: Fever typically develops within the first 24 hours of the MI and may last for several days.
5. Explanation for Pain during MI:
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Ischemia: The blockage of blood flow to the heart muscle (ischemia) causes a buildup of lactic acid and other metabolic byproducts, leading to pain.
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Stretching of the Heart Muscle: As the heart muscle struggles to function despite inadequate blood supply, it can stretch and cause pain.
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Nerve Stimulation: The ischemic heart muscle stimulates sensory nerves, causing pain signals to be transmitted to the brain.
Remember: This is a summary of the case study and potential responses. It's important to consult reliable medical resources and healthcare professionals for accurate diagnosis and treatment.
Sample Answer
.D. Case Study:
1. Contributing Factors to Iron Deficiency Anemia:
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Menorrhagia: Heavy menstrual bleeding is a significant contributor to iron loss, especially when combined with frequent pregnancies.
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Frequent Pregnancies: Each pregnancy depletes iron stores, and having five pregnancies within four years places a substantial strain on J.D.'s iron reserves.
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Inadequate Iron Intake: J.D. may not be consuming enough iron-rich foods to replenish her stores, especially given her increased iron demands.
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Possible Malabsorption: Long-term use of ibuprofen and omeprazole can potentially disrupt iron absorption in the gut.
2. Reasons for Constipation and Dehydration:
The case study doesn't directly mention constipation or dehydration, but it's possible that J.D.'s fatigue and weakness are contributing factors.
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Fatigue and Weakness: These symptoms can lead to reduced physical activity and decreased fluid intake, potentially contributing to constipation and dehydration.
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Iron Deficiency: Iron deficiency anemia can lead to weakness and fatigue, further impacting daily activities and potentially causing constipation.
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Medications: Ibuprofen can cause gastrointestinal upset, including constipation, and omeprazole, while used to prevent ulcers, can also lead to constipation.
3. Importance of Vitamin B12 and Folic Acid in Erythropoiesis:
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B12 and Folic Acid: Both are essential for DNA synthesis and cell division, crucial processes in red blood cell production (erythropoiesis).
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B12 Deficiency: Can lead to megaloblastic anemia, characterized by large, immature red blood cells (megaloblasts).
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Folic Acid Deficiency: Also results in megaloblastic anemia, but with smaller megaloblasts compared to B12 deficiency.