44 - Anemia Case Study Flashcards
What is the chief complain of our anemia case study?
- 22 year old white female, Amy W., presents to your office for pre-op surgical consult prior to elective hammertoe repair of the 2nd toe, bilateral, under local anesthesia
What is the patient’s history?
- Family history of hammertoes
- Patient wears high-heels regularly in her job as a fashion model and finds it more difficult due to hammertoes
- Relates that most members of her family have long 2nd toes
Describe the other patient history
- MH: unremarkable = SH: no alcohol, 4 cans of diet Coke®/day, no illicit drugs, vegetarian, works out daily in health club - FH: unremarkable - Drugs: None - Allergies: None - ROS: occasional fatigue
What did the pre-op CBC indicate?
- Low hemoglobin -anemia
- Low MCV -microcytic anemia
Hb –> if there is low hemoglobin, you have anemia, this is the clinical definition (NOT RBCs, Hb***)
MCV –> mean corpuscular volume, tells you the size of the RBCs – if size is lower than normal, it is MICROCYTIC anemia , if size is higher than normal, it is MACROCYTIC anemia
What is the next step?
Call the patient to ask questions
What questions will you ask?
Is there any family history of anemia or blood disorders?
- Nephew receives regular blood transfusions for clotting problem
Do you have normal menstruation?
- “Heavy” bleeding
Do you take vitamins?
- Yes, with an iron supplement as suggested by OB-GYN
Have you been diagnosed with an iron deficiency anemia?
- “Yes, by my OB-GYN who is also my PCP”
What will you want to call and ask the OBGYN?
Past blood work
Nurse relates that last 4 CBC’s taken at time of annual PAP smear and pelvic exam showed similar values. No other hematological studies performed.
You decide to do a peripheral blood smear. What would you see?
Smear shows microcytes with…
- Anisocytosis (different sizes)
- Poikilocytosis (different shapes)
- Hypochromia (excess pallor in center of RBC)
What is your differential diagnosis?
Microcytic Anemia** –> you will now look at ISAT for the major differential of what is going on **
ISAT
I - Iron deficiency anemia
S - Sideroblastosis
A - Anemia of chronic disease
T - Thalassemia
What tests will you order?
Serum ferritin-42 ug/ml (10-300)
With a normal ferritin, diagnosis of iron deficiency is unlikely
What do you order next?
Hemoglobin electrophoresis-increased hemoglobin A2
What is the diagnosis?
Beta thalassemia trait
This is more common in Mediterranean populations - could have asked about background - she is Italian
Like you will find out, Sickle cell anemia and thalassemia are blood disorders that have evolved to protect people from malaria***
What is beta thalassemia trait?
- Genetic disease characterized by globin chain imbalance
- Mutations partially or completely inactivate production of a globin chain leading to imbalance in ratio of α- and β-globin chains
- Alpha has decreased alpha chains
- Βeta has decreased beta chains
What does it mean if you have the “trait”?
Trait: Hb production reduced in RBC, leading to microcytic anemia, but does NOT affect RBC production and survival
What does it mean if you have the “major”?
Major: profound imbalance in chain production with affects on RBC production or survival
What should you know about the beta trait?
- Autosomal recessive disorder
- Child has 25% chance of acquiring disorder if both parents have the trait
- Patients are asymptomatic
- Increased alpha chains need something to bind to, so they usually combine with δ chains to form HbA2 (α2δ2) which increases in concentration above normal 4-7%
- No surgical precautions necessary
- No treatment
What you NEED to know is the mnemonic for the different types of anemia
“I sat in a ham damn”
Microcytic anemia
I-iron deficiency
S-sideroblastic anemia
A-anemia of chronic disorder
T-thalassemia
Normocytic anemia
I-infiltrative bone marrrow disorder
N-nutritional anemia
A-anemia of chronic disorder
H-hemolytic anemia
A-anemia of renal insufficiency
M-myelodysplastic anemia
Macrocytic anemia
D-drugs [metformin (glucophage®)]
A-alcohol
M-malabsorption syndromes
N-nutritional anemias
What is the most common anemia you will see clinically?
MOST COMMON ANEMIA (that you will see clinically based on your patient population) – normocytic anemia due to chronic disorder
Chronic diseases cause normocytic anemia
Can you still take your patient to surgery?
Yes
But you do need to recommend genetic counseling to the patient
