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, about21?2years 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 pep-tic 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 being treated with a diuretic and a centrally acting antihypertensive drug. She has had no previous surgeries.
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.
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.
Expert Solution Preview
In this case, we have two patient scenarios – one related to hematopoietic issues and the other related to cardiovascular problems. We will address each case study question separately.
Answer to Case Study Questions (Hematopoietic):
1. Name the contributing factors on J.D. that might put her at risk to develop iron deficiency anemia.
Possible contributing factors that put J.D. at risk for developing iron deficiency anemia include:
– Increased blood loss due to intermenstrual bleeding and menorrhagia
– Multiple pregnancies within a short period of time, leading to depletion of iron stores
– Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, which can cause gastrointestinal bleeding
– Use of omeprazole to prevent gastrointestinal bleeding, which may reduce iron absorption
2. Within the case study, describe the reasons why J.D. might be presenting constipation and/or dehydration.
J.D. may be experiencing constipation and dehydration due to the following reasons:
– Iron deficiency anemia can lead to reduced gastrointestinal motility, causing constipation.
– Heavy menstrual flow and intermenstrual bleeding can lead to fluid loss, contributing to dehydration.
3. Why are Vitamin B12 and folic acid important in erythropoiesis? What abnormalities can deficiency of these vitamins cause in red blood cells?
Vitamin B12 and folic acid are important for erythropoiesis (red blood cell production). Their deficiency can cause several abnormalities in red blood cells, including:
– Macrocytic (larger than normal) red blood cells: Deficiency of Vitamin B12 and/or folic acid can impair DNA synthesis during erythropoiesis, leading to ineffective maturation of red blood cells.
– Hypersegmented neutrophils: In Vitamin B12 deficiency, neutrophils can have too many lobes in their nuclei, known as hypersegmentation.
– Anemia: Both Vitamin B12 and folic acid deficiency can lead to megaloblastic anemia, characterized by large, abnormal red blood cells and a decreased number of mature red blood cells.
4. The gynecologist suspects 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 that are positive for iron deficiency anemia.
Clinical symptoms that can support the diagnosis of iron deficiency anemia in J.D. include:
– Intermenstrual bleeding and menorrhagia: Excessive blood loss can deplete iron stores in the body.
– Extreme fatigue and weakness: Iron is essential for the production of hemoglobin, which carries oxygen throughout the body. Iron deficiency can lead to reduced oxygen-carrying capacity and result in fatigue and weakness.
– Pale skin and conjunctiva: Reduced red blood cell production can lead to paleness of the skin and inner eyelids (conjunctiva).
– Increased urinary frequency and mild incontinence: Iron deficiency can affect muscle function, including those responsible for bladder control, leading to increased urinary frequency and mild incontinence.
5. 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.
Signs of iron deficiency anemia can include:
– Pallor: Reduced red blood cell production can lead to a pale appearance of the skin, lips, and inner eyelids.
– Koilonychia (spoon-shaped nails): Severely iron-deficient individuals may develop spoon-shaped nails.
– Glossitis: Iron deficiency can lead to inflammation of the tongue, known as glossitis.
– Angular cheilitis: Cracks and fissures at the corners of the mouth can be observed in iron deficiency anemia.
6. Lab 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 and list appropriate recommendations and treatments for J.D.
Based on J.D.’s lab results and symptoms, appropriate recommendations and treatments for iron deficiency anemia may include:
– Iron supplementation: Oral iron supplements can help replenish iron stores in the body. It is important to choose an appropriate iron preparation and provide counseling on potential side effects (e.g., constipation, nausea).
– Dietary modifications: J.D. should be counseled on consuming iron-rich foods such as red meat, poultry, fish, tofu, peas, and beans.
– Vitamin C supplementation: Vitamin C enhances iron absorption, so adding a vitamin C supplement or consuming vitamin C-rich foods (e.g., citrus fruits, strawberries) can aid in iron absorption.
– Evaluation of gastrointestinal bleeding: To identify and address the potential cause of iron loss, further evaluation of gastrointestinal bleeding may be necessary.
Answer to Case Study Questions (Cardiovascular):
1. For patients at risk of developing coronary artery disease and patients diagnosed with acute myocardial infarct, describe the modifiable and non-modifiable risk factors.
Modifiable risk factors for developing coronary artery disease and acute myocardial infarction include:
– Unhealthy diet
– Sedentary lifestyle
– High cholesterol levels
– Diabetes mellitus
Non-modifiable risk factors include:
– Gender (males are generally at higher risk)
– Family history of early heart disease
– Genetic factors
2. What would you expect to see on Mr. W.G.’s EKG, and which findings described in the case are compatible with the acute coronary event?
On Mr. W.G.’s EKG, we would expect to see changes indicative of an acute coronary event. These changes may include:
– ST-segment elevation or depression
– T-wave inversion
– Development of Q-waves
The findings in the case that are compatible with an acute coronary event include:
– Chest discomfort that spreads upward into the neck and lower jaw
– Nausea and pain intensification with exertion
3. 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?
The most specific laboratory test to confirm an acute myocardial infarction is measurement of cardiac troponin levels. Cardiac troponins are proteins released into the bloodstream when there is damage to the heart muscle. Troponin levels rise within a few hours after myocardial infarction and remain elevated for several days, making it a reliable and specific marker for myocardial injury.
4. How do you explain that Mr. W.G.’s 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.
After a myocardial infarction, Mr. W.G.’s temperature may increase due to the inflammatory response triggered by myocardial tissue damage. This inflammatory response can lead to the release of cytokines and other mediators, causing a systemic reaction, including fever. The fever is usually observed within the first few days after the infarction and may last for a variable duration depending on the individual’s immune response and the extent of tissue damage.
5. Explain to Mr. W.G. why he was experiencing pain during his myocardial infarct. Elaborate and support your answer.
During the myocardial infarction, Mr. W.G. experienced pain due to myocardial ischemia, resulting from a disruption in the blood flow to his heart muscle. The pain, known as angina, is caused by the insufficient supply of oxygen and nutrients to the cardiac cells. The lack of oxygen leads to the accumulation of metabolic waste products, tissue damage, and the activation of pain receptors. The spreading of pain to the neck and lower jaw can be explained by the phenomenon of referred pain, where sensation from the heart is perceived as pain in distant areas, due to the overlapping of nerve pathways.