Case Study: Anemia
Case Study: Anemia
Ms. A most likely has blood loss anemia, specifically, chronic blood loss. From the patient history, it is evident that she has had chronic blood loss due to menorrhagia for about ten to twelve years. Menorrhagia is heavy menstrual flow, which may be prolonged, and may lead to loss of large amount of blood in every menstrual cycle. A history of intake of high doses of aspirin (about 6000mg) per day for the dysmenorrhea for about six days in every menstrual cycle, almost equivalent to monthly, may have contributed to chronic blood loss. Ms. A also reports to take aspirin during summer months while she plays golf to avoid joint stiffness. Aspirin, pharmacologically known as acetylsalicylic acid (ASA), has antiplatelet effects through inhibition of cyclooxygenase (COX) enzyme by irreversible acetylation. This enzyme enables synthesis of thromboxane 2 in platelets, thromboxane 2 enhances platelet aggregation, and hence platelet function in coagulation. This irreversible antiplatelet effect of aspirin leads to prolonged bleeding, which lasts 8 to 10 days until there is synthesis of new platelets.
The high dose of aspirin taken frequently by Ms. A may produce significant gastrointestinal effects. This is through the inhibition of the production of prostaglandins E2 and F2 alpha, which have a protective effect on the stomach and small intestine through mucus production. Lack of these prostaglandins leads to increased gastric secretion and less mucus protection. This predisposes to epigastric distress, ulceration with hemorrhage, which may develop into peptic ulcer disease. Prolonged bleeding caused by the concomitant intake of aspirin in large doses may be exacerbate the gastrointestinal hemorrhage.
The symptoms at presentation by Ms. A include gradual increase in shortness of breath, easy fatigability (described as low levels of energy and enthusiasm) worse during menstruation and light-headedness associated with exertion. This is the typical clinical picture of anemia due to chronic blood loss. The chronic and continuous loss of small amounts of blood through menorrhagia and gastrointestinal hemorrhage does not alter blood volume significantly. This is because initially there is compensation by expansion of plasma volume by the body through production of albumin; hence, symptoms are not of sudden onset. The signs and symptoms associated with chronic blood loss are of gradual onset and worsen only due to certain factors including exertion, infection and hypovolemia from other causes such as diarrhea and vomiting. The vital signs taken indicated temperature within normal ranges, increased heart rate and increased respiratory rate. Due to the chronic blood loss, there is resultant hypotension due to hypovolemia. The body has adopted a compensatory mechanism through tachycardia, tachypnea to ensure adequate perfusion of organs and peripheries.
The laboratory findings from the blood work up of Ms. A reveal a low level of hemoglobin at 8g/dl as compared to the normal hemoglobin level of 12mg/dl to 16mg/dl in females. This is due to continual loss of small amounts of blood in chronic blood loss leading to reduced amount of iron stores and defective erythropoiesis. The hematocrit level is at 32%, which is low as compared to the normal level of 36% to 45% in women. The erythrocyte count is low at 3.1*10/mm as compared to the normal level of 4.5*10/mm to 5.1*10/mm in women. This is because of the decrease in the volume of packed red cells and reduced number of erythrocytes due to defective erythropoiesis. This results from iron deficiency due to depletion of iron stores due to blood loss. The blood smear shows a microcytic picture meaning that the red blood cells are smaller than normal and the mean corpuscular volume (MCV) is low. The red blood cells are hypochromic and are therefore pale as compared to their normal red color. These occur in anemia due to chronic blood loss due to the resultant iron deficiency caused by loss of blood with depletion of iron stores and reduction in hemoglobin synthesis. The reticulocyte count is at 1.5%, which is within the normal ranges of 0.5% to 1.5% for an adult. This value is the higher normal as compared to the reference ranges. During the initial stages of blood loss, reticulocyte count increases greatly due to the attempt by the bone marrow to compensate for the reduced erythrocyte count due to blood loss. With slow, continuous blood loss, the reticulocyte count drops back to normal as the bone marrow adapts to the blood loss with the production of microcytic hypochromic red blood cells.
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