nursing case study on anemia

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Patient Case Presentation

Patient  Overview

M.J. is a 25-year-old, African American female presenting to her PCP with complaints of fatigue, weakness, and shortness of breath with minimal activity. Her friends and family have told her she appears pale, and combined with her recent symptoms she has decided to get checked out. She also states that she has noticed her hair and fingernails becoming extremely thin and brittle, causing even more concern. The patient first started noticing these symptoms a few months ago and they have been getting progressively worse. Upon initial assessment, her mucosal membranes and conjunctivae are pale. She denies pain at this time, but describes an intermittent dry, soreness of her tongue.

Vital Signs:

Temperature – 37 C (98.8 F)

HR – 95

BP – 110/70 (83)

Lab Values:

Hgb- 7 g/dL

Serum Iron – 40 mcg/dL

Transferrin Saturation – 15%

Medical History

• Diagnosed with peptic ulcer disease at age 21 – controlled with PPI pharmacotherapy
• IUD placement 3 months ago – reports an increase in menstrual bleeding since placement

Surgical History

• No past surgical history reported

Family History

• Diagnosis of iron deficiency anemia at 24 years old during pregnancy with patient – on daily supplement
• Otherwise healthy
• Diagnosis of hypertension – controlled with diet and exercise
• No siblings

Social History

• Vegetarian – patient states she has been having weird cravings for ice cubes lately
• Living alone in an apartment close to work in a lower-income community
• Works full time at a clothing department store

Learn about the nursing care management of patients with anemia .

Table of Contents

What is anemia, classification, hypoproliferative anemia, hemolytic anemia, clinical manifestations, complications, assessment and diagnostic findings, medical management, nursing assessment, planning & goals, nursing interventions, discharge and home care guidelines, documentation guidelines.

Anemia is a condition that is slowly rising in cases across all countries. Every age and every stage can be affected by anemia, and though others may consider this as a simple condition, it could blow out of proportion if left untreated.

• Anemia is a condition in which the hemoglobin concentration is lower than normal.
• Anemia reflects the presence of fever than the normal number of erythrocytes within the circulation.
• Anemia is not a specific disease state but an underlying disorder and the most common hematologic condition.

A physiologic approach classifies anemia according to whether the deficiency in erythrocytes is caused by a defect in their production, by their destruction, or by their loss.

• Hypoproliferative anemias . In hypoproliferative anemias, the marrow cannot produce adequate numbers of erythrocytes.
• Hemolytic anemias . There is premature destruction of erythrocytes that results in the liberation of hemoglobin from the erythrocytes into the plasma ; the released hemoglobin is then converted into bilirubin , therefore bilirubin concentration rises.
• Bleeding anemias . Bleeding anemias are caused by the loss of erythrocytes in the body.

Pathophysiology

The pathophysiology of anemias is drawn according to the cause of the disease.

• Decreased erythrocyte production . There is decreased erythrocyte production, reflected by an inappropriately normal or low reticulocyte count .
• Marrow damage . As a result of marrow damage, inadequate production of erythrocyte occurs due to the medications or chemicals or from a lack of factors.
• Premature destruction . Premature destruction of erythrocytes results in the liberation of hemoglobin from the erythrocytes into the plasma.
• Conversion . The released hemoglobin is converted in large part to bilirubin, resulting in high concentration of bilirubin.
• Erythropoietin production . The increased erythrocyte destruction leads to tissue hypoxia which stimulates erythropoietin production.
• Increased reticulocytes . This increased production is reflected in an increased reticulocyte count as the bone marrow responds to the loss of erythrocytes.
• Hemolysis . Hemolysis is the end result, which can result from an abnormality within the erythrocyte itself or within the plasma, or from direct injury to the erythrocyte within the circulation.

It is usually possible to determine whether the presence of anemia is caused by destruction or inadequate production of erythrocytes on the basis of the following factors.

• Response . The marrow’s response to decreased erythrocytes as evidenced by an increased reticulocyte count in the circulation blood .
• Proliferation . The degree to which young erythrocytes proliferate in the bone marrow and the manner in which they mature as observed in the bone marrow biopsy .
• Destruction . The presence or absence of end products of erythrocyte destruction within the circulation.

In general, the more rapidly the anemia develops, the more aggressive is its symptoms.

• Decreased hemoglobin . A patient with anemia has hemoglobin levels between 9 to 11 g/dL.
• Fatigue . Fatigue occurs because there is inadequate oxygen levels in the tissues that should have been carried by hemoglobin.
• Tachycardia . The heart compensates for the decrease in oxygen by pumping out more blood so it can reach peripheral tissues in the body.
• Dyspnea . Difficulty of breathing occurs because of the decreased concentrations of oxygen in the blood.
• With decreased hemoglobin that serves as the pigment in the red blood cells, the patient may become pale because of the lack or decrease in the pigment that is hemoglobin.

To prevent anemia, lifestyle modifications must be made.

• Diet rich in iron . Ingestion of iron-rich foods could help prevent anemia because it adds to the hemoglobin in the body.
• Iron supplements . Iron supplements can also be taken to increase the hemoglobin levels in the body.

Anemia has general complications and this includes:

• Heart failure . As the heart compensates by pumping faster than the normal rate, the heart muscles gradually weaken until the muscles wear out and the heart fails to function.
• Paresthesias . Paresthesias develop when the muscles do not have enough oxygen delivered to them.
• Delirium . Insufficient oxygen in the brain results in delirium and is considered a fatal complication of anemia.

A number of hematologic studies are performed to determine the type and cause of anemia.

• Blood studies . In an initial evaluation , the hemoglobin, hematocrit, reticulocyte count, and RBC indices, particularly the mean corpuscular volume and red cell distribution width are taken to assess for the presence of anemia.
• Iron studies . Serum iron level, total iron binding capacity, percent saturation, and ferritin, as well as serum vitamin B12 and folate levels, are all useful in diagnosing anemia.
• CBC values . The remaining CBC values are useful in determining whether the anemia is an isolated problem or part of another hematologic condition.

Management of anemia is directed towards correcting or controlling the cause of anemia.

• Nutritional supplements . Use of nutritional supplements should be appropriately taught to the patient and the family because too much intake cannot improve anemia.
• Blood transfusion . Patients with acute blood loss or severe hemolysis may have decreased tissue perfusion from decreased blood volume or reduced circulating erythrocytes, so transfusion of blood would be necessary.
• Intravenous fluids . Intravenous fluids replace the lost volumes of blood or electrolytes to restore them to normal levels.

Nursing Management

The management of anemia by nurses should be accurate and appropriate so that objectives and goals would be achieved.

The assessment of anemia involves:

• Health history and physical exam . Both provide important data about the type of anemia involved, the extent and type of symptoms it produces, and the impact of those symptoms on the patient’s life.
• Medication history . Some medications can depress bone marrow activity, induce hemolysis, or interfere with folate metabolism.
• History of alcohol intake . An accurate history of alcohol intake including the amount and duration should be obtained.
• Family history . Assessment of family history is important because certain anemias are inherited.
• Athletic endeavors . Assess if the patient has any athletic endeavor because extreme exercise can decrease erythropoiesis and erythrocyte survival.
• Nutritional assessment . Assessing the nutritional status and habits is important because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folic acid.

Based on the assessment data, major nursing diagnosis for patients with anemia include:

• Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the blood.
• Altered nutrition , less than body requirements , related to inadequate intake of essential nutrients.
• Altered tissue perfusion related to insufficient hemoglobin and hematocrit.

The major goals for a patient with anemia include:

• Decreased fatigue
• Attainment or maintenance of adequate nutrition.
• Maintenance of adequate tissue perfusion .
• Compliance with prescribed therapy.
• Absence of complications.

Nursing interventions are based on the data assessed by the nurse and on the symptoms that the patient manifests.

To manage fatigue :

• Prioritize activities . Assist the patient in prioritizing activities and establishing balance between activity and rest that would be acceptable to the patient.
• Exercise and physical activity . Patients with chronic anemia need to maintain some physical activity and exercise to prevent the deconditioning that results from inactivity.

To maintain adequate nutrition:

• Diet . The nurse should encourage a healthy diet that is packed with essential nutrients.
• Alcohol intake . The nurse should inform the patient that alcohol interferes with the utilization of essential nutrients and should advise the patient to avoid or limit his or her intake of alcoholic beverages.
• Dietary teaching . Sessions should be individualized and involve the family members and include cultural aspects related to food preference and preparation.

To maintain adequate perfusion:

• Blood transfusion monitoring . The nurse should monitor the patient’s vital signs and pulse oximeter readings closely.

To promote compliance with prescribed therapy:

• Enhance compliance . The nurse should assist the patient to develop ways to incorporate the therapeutic plan into everyday activities.
• Medication intake . Patients receiving high-dose corticosteroids may need assistance to obtain needed insurance coverage or to explore alternative ways to obtain these medications.

Included in the expected patient outcomes are the following:

• Reports less fatigue .
• Attains and maintains adequate nutrition.
• Maintains adequate perfusion.

Health education is the main focus during discharge and for the home care.

• Instruct the patient to consume iron-rich foods to help build-up hemoglobin stores.
• Iron supplements. Enforce strict compliance in taking iron supplements as prescribed by the physician.
• Follow-up. Stress the need for regular medical and laboratory follow-up to evaluate disease progression and response to therapies.

The data to be documented consists the following:

• Baseline and subsequent assessment findings to include signs and symptoms.
• Individual cultural or religious restrictions and personal preferences.
• Plan of care and persons involved.
• Teaching plan.
• Client’s responses to teachings, interventions, and actions performed.
• Attainment or progress toward desired outcome.
• Long-term needs, and who is responsible for actions to be taken.

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The Case Report of a 97-Year-Old Patient With Chronic Anemia and Hemoglobin Value of 1.7 g/dl and Review of the Literature

Andreas kyvetos, stefani panayiotou, panagiota voukelatou, ioannis vrettos, georgios boulmetis.

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Andreas Kyvetos [email protected]

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Accepted 2022 Apr 20; Collection date 2022 Apr.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Although hemoglobin levels beneath 6.5 g/dl are considered to be life-threatening and the patients theoretically suffer from a cluster of symptoms, few cases of patients who seek medical assistance when their hemoglobin levels had fallen beneath 3 g/dl have been reported in the literature. Here, we describe the case of a 97-year-old patient who was transferred to the emergency department with dyspnea and the initial screening tests showed a hemoglobin level of 1.7 g/dl, due to iron deficiency. The patient was hemodynamically stable, and no ischemic lesions were seen on the electrocardiogram. His dyspnea was due to a lower respiratory tract infection and bilateral pleural effusion. He was bedridden for two years. His absence of physical activity in combination with the slow onset of anemia and the absence of severe underlying pulmonary and cardiovascular diseases could hide the symptoms until additional stressful events, such as the respiratory tract infection and the deterioration of heart function, occurred. So, we must keep in mind that in elderly patients with reduced physical activity and without severe pulmonary and cardiovascular comorbidities, the symptoms of severe anemia may go unnoticed until hemoglobin reaches life-threatening levels.

Keywords: adaptive, deficiency, iron, anemia, severe

Introduction

The symptoms of anemia like dyspnea, tachypnea, palpitations, cold skin, heart failure, cognitive dysfunction, etc. depend, inter alia, on the severity of anemia, the rapidity of its onset, the age, and the physiological status of the patient. Various adaptive mechanisms are mobilized by the human body in order to counterbalance the effects of anemia, although almost every organ system is finally affected [ 1 ]. The most significant adaptive responses involve the cardiovascular system. These adaptive responses include increased cardiac output and redistribution of blood flow toward the heart and central nervous system and away from the splanchnic vascular beds [ 2 ].

In cases of chronic anemia, it has been postulated that the hyperkinetic response in patients at rest, occurs only when hemoglobin level falls beneath 7 g/dl [ 3 ]. Moreover, in hemoglobin levels beneath 7.5 g/dl, 100 ml of arterial blood contains 10 ml of oxygen instead of 20 ml in healthy subjects [ 1 ]. Nevertheless, certain symptoms or complications experienced by a patient cannot be determined with the accuracy of hemoglobin levels alone [ 4 ]. Heart, lung, and cerebrovascular diseases, as well as age, may limit the adaptive responses to anemia [ 2 ]. On the other hand, in young and otherwise healthy persons, chronic anemia may remain unnoticed until hemoglobin level falls beneath a critical level or episodes of exertional stress occur [ 1 ].

According to several grading systems for anemia, hemoglobin levels beneath 6.5 g/dl are considered life-threatening [ 5 ], and the patient theoretically suffers from a cluster of symptoms. However, a few cases of patients have been reported in the literature [ 6 - 12 ] who seek medical assistance when their hemoglobin levels had fallen beneath 3 g/dl and therefore their hematocrit levels were beneath 10%.

In this report, we describe the case of a “too hard to die” 97-year-old patient who was transferred to the emergency department with dyspnea and the initial screening tests showed a hemoglobin level of 1.7 g/dl, and we review and discuss the reported cases of other “too hard to die” patients with hemoglobin concentrations beneath 3.0 g/dl due to chronic anemia. This paper is an extended version of a work presented at the 24ο Panhellenic Congress of Internal Medicine, Athens, Greece, on 3-6 November 2021.

Case presentation

A 97-year-old patient was admitted to the emergency department due to shortness of breath for one week, without other symptoms. According to his medical history, the patient suffered from anemia, treated with 247.25 mg ferrous sulfate, 5 mg folic acid daily, and hypothyroidism treated with levothyroxine sodium 75 mcg. His relatives were aware of his anemia but they preferred to treat it with per-os medication without investigating the cause of the anemia. They reported that the patient’s stools for several days were tarry but they believed it to be due to the iron he was receiving. Six months ago, he was diagnosed with pulmonary embolism which was effectively managed with apixaban 110 mg twice daily and two years ago he had an ischemic stroke that left him bedridden.

At the time of presentation, he appeared pale and lethargic (Glasgow Coma Scale 7/15) with tachypnea (30 breaths/min). Bilateral crepitations and rhonchi were present in lung auscultation. There was a systolic murmur throughout the precordium. A digital rectal examination was performed and it was negative for melena. His blood pressure was 120/60 mmHg with a regular pulse rate of 90 beats/min. Other findings from the physical examination were unremarkable. The laboratory test revealed hypochromic microcytic anemia, with hemoglobin value of 1.7 g/dl (normal range: 12-16 g/dl), hematocrit 6.9% (normal range: 37-48%), red blood cell count of 1.53 Μ/ml (normal range: 4.5-6.3 Μ/ml), mean corpuscular volume of 75 fl (normal range: 80-96 fl), and mean corpuscular hemoglobin of 23.8 pg (normal range: 27-34 pg). The complete blood count was examined twice in order to avoid a laboratory error in measurement. Other laboratory results showed: white blood cells 6.47 K/μl (normal range: 4.0-11.0 Κ/μl), platelets 121 Κ/μl (normal range: 150-400 Κ/μl), C-reactive protein 3.56 mg/dl (normal range: <0.5 mg/dl), creatinine 1.7 mg/dl (normal range: 0.6-1.4 mg/dl), urea 135 mg/dl (normal range: 10-50 mg/dl), total bilirubin 0.7 mg/dl (normal range: 0.2-1 mg/dl), ferritin 20 ng/ml (normal range: 11-204 ng/ml), folicid acid >40 ng/ml (normal range: 3.1-20 ng/ml), cobalamin 700 pg/ml (normal range: 187-883 pg/ml), erythrocyte sedimentation rate 10 mm/h (normal range: 2-20 mm/h), direct Coombs test negative, a normal urinalysis test, high sensitivity troponin I (HS-TnI) 34 pg/ml (normal range: <11.6 pg/ml), and brain natriuretic peptide (BNP) 804.30 pg/ml (normal range: <100 pg/ml). No ischemic lesions were seen on the electrocardiogram (Figure  1 ) and the second sample of HS-TnI was within the normal range. Hematological consultation was requested and the blood smear revealed normal platelets count of 199 Κ/μl and microcytic red blood cells with hypochromia. Erythropoietin levels and total iron-binding capacity were not performed due to the lack of these laboratory tests in our hospital.

Figure 1. The electrocardiogram of the patient showing the absence of ischemic lesions.

Cardiac echocardiography was performed that showed signs of heart failure with preserved ejection fraction and grade I diastolic dysfunction. A chest CT scan revealed a lower respiratory tract infection and a bilateral pleural effusion (Figure  2 ) compatible with his heart failure. An abdominal CT scan was performed that did not reveal any pathology.

Figure 2. Chest CT scan images a) Lung window b) Mediastinal window.

It revealed a lower respiratory tract infection (blue arrows) and bilateral pleural effusion (red arrows).

The patient was treated with furosemide, ceftriaxone 2 g once daily and clindamycin 600 mg three times daily. A total of 5 units of packed RBCs were transfused resulting in a hemoglobin value of 8.7 g/dl. The renal function at the admission was impaired but gradually it was improved and the discharge creatinine was 0.8 mg/dl. Gastroscopy and colonoscopy were scheduled but his relatives refused any further investigation to identify the cause of anemia. Although the investigation for the cause of anemia was inadequate, the history of tarry stools in a patient receiving anticoagulant, in combination with a ferritin value of 20 ng/ml made us assume that the main cause of his anemia was chronic bleeding from the gastrointestinal tract. So, he received 1 g of intravenous iron. The patient had a remarkable recovery to his preadmission state and he was discharged home 11 days after.

Our patient had one of the lowest hemoglobin levels that have ever been reported. To our knowledge, the lowest hemoglobin concentration that has ever been reported in a non-trauma patient is 1.2 g/dl (hematocrit of 3.0%) due to paroxysmal nocturnal hemoglobinuria. The 21-year-old male patient was presented with profound weakness and abdominal pain, although hemodynamically stable [ 6 ]. The second-lowest reported hemoglobin was 1.3 g/dl (hematocrit of 4.7%) and it was due to iron deficiency, because of chronic uterine bleeding [ 7 ]. The patient was a 44-year-old woman with weakness and dyspnea at rest. She had regular pulses, normal arterial pressure, and 25 breaths per minute. She had severe lactic acidosis and inverted T waves in leads III, aVF in her ECG.

Likewise, an extremely low hemoglobin level, in a patient with chronic anemia, has been reported by Jost et al. They presented a 29-year-old woman with celiac disease, bulimia nervosa, and iron-deficiency anemia. She had a hemoglobin level of 1.7 g/dl. She was malnourished and she reported exhaustion, fatigue, and abdominal pain but no critical symptoms [ 8 ]. On the other hand, a 76-year-old woman had critical symptoms with hemoglobin 2.4 g/dl due to gastric adenocarcinoma. She was hemodynamically unstable and reported increased fatigue, reduced activity, intermittent nausea or vomiting, and melena. Clarke and Weston-Smith reported a case of folate deficiency in a 50-year-old woman with hemoglobin of 2.6 g/dl. They reported that the patient was stable, alert, and keen to avoid admission. She had a soft ejection systolic murmur and her ECG was in normal sinus rhythm of 90 beats per minute with ST-segment depression in lateral leads [ 10 ].

Another case that was presented by Reibke et al. was a 32-year-old male with hemoglobin 2.9 g/dl due to B12 deficiency and minor beta-thalassemia [ 11 ]. Finally, extremely low hemoglobin levels have been reported by Bhatia et al., who performed coronary hemodynamic studies on 14 patients with chronic anemia. They reported three patients with hemoglobin levels ≤3.0 mg/dl; they had hemoglobin levels of 1.6 mg/dl, 2.4 mg/dl, and 3.0 mg/dl, and all of them were between 23 to 25 years old. Two of them had iron-deficiency anemia due to ankylostomiasis and the third had B12 deficiency [ 12 ].

All of these patients had no underlying pulmonary and cardiovascular diseases and they developed gradually severe anemia. This gradual onset allowed the compensatory mechanisms to take place and so, the patients arrived at the emergency departments with hemoglobin levels much lower than that considered to be life-threatening. The difference with our patients is that almost all, with one exception [ 9 ], were less than 50 years old and so, theoretically, they had satisfactory adaptive responses to anemia. The exception [ 9 ] was referred to as a 76-year-old woman with gastric adenocarcinoma that arrived at the emergency department with hypotension and tachycardia. This woman had symptoms compatible with anemia for several weeks.

In contrast, our patient was hemodynamically stable, and he had no profound symptoms until the time dyspnea was developed due to both the lower respiratory tract infection and also the deterioration of cardiac function which was triggered probably both by anemia and the respiratory tract infection. What hid the patient’s symptoms from his relatives, according to our opinion, was the non-existent, even the minimal, physical activity of this elderly. His absence of physical activity in combination with the slow onset of anemia and the absence of severe underlying pulmonary and cardiovascular diseases could hide the symptoms until the time of additional stressful events, such as the respiratory tract infection and the deterioration of heart function, occurred.

Conclusions

Symptomatic anemia is a common finding in elderly patients. Whereas, in elderly patients with reduced physical activity and without severe pulmonary and cardiovascular comorbidities, the symptoms of severe anemia may go unnoticed until hemoglobin reaches life-threatening levels. Careful surveillance of these patients is mandatory with regular clinical examination and laboratory blood tests, especially for those who are receiving anticoagulant therapy.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

• 1. Symptomatology of anemia. Ludwig H, Strasser K. Semin Oncol. 2001;28:7–14. doi: 10.1016/s0093-7754(01)90206-4. [ DOI ] [ PubMed ] [ Google Scholar ]
• 2. Review of physiologic mechanisms in response to anemia. Hebert PC, Hu LQ, Biro GP. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1255887/ CMAJ. 1997;156:0–40. [ Google Scholar ]
• 3. The hemodynamic response to chronic anemia. Duke M, Abelmann WH. Circulation. 1969;39:503–515. doi: 10.1161/01.cir.39.4.503. [ DOI ] [ PubMed ] [ Google Scholar ]
• 4. Severe anemia. Clinical observations in 100 patients with very low hemoglobin levels. Al-Mondhiry H, Al-Hilali A. Arch Intern Med. 1979;139:1053–1054. doi: 10.1001/archinte.139.9.1053. [ DOI ] [ PubMed ] [ Google Scholar ]
• 5. Practitioners' practical model for managing cancer-related anemia. Smith RE Jr, Tchekmedyian S. https://pubmed.ncbi.nlm.nih.gov/12380955/ Oncology (Williston Park) 2002;16:55–63. [ PubMed ] [ Google Scholar ]
• 6. Lactic acidosis secondary to severe anemia in a patient with paroxysmal nocturnal hemoglobinuria. Essex DW, Jin DK, Bradley TP. https://pubmed.ncbi.nlm.nih.gov/12380955/ Am J Hematol. 1997;55:110–111. doi: 10.1002/(sici)1096-8652(199706)55:2<110::aid-ajh10>3.0.co;2-i. [ DOI ] [ PubMed ] [ Google Scholar ]
• 7. Life-threatening iron deficiency anemia and profound lactic acidosis due to uterine fibroid bleeding. Ntalianis A, Mandrekas K, Papamichael C, Anastasiou-Nana MI. Am J Emerg Med. 2009;27:377–370. doi: 10.1016/j.ajem.2008.08.014. [ DOI ] [ PubMed ] [ Google Scholar ]
• 8. Very severe iron-deficiency anemia in a patient with celiac disease and bulimia nervosa: a case report. Jost PJ, Stengel SM, Huber W, Sarbia M, Peschel C, Duyster J. Int J Hematol. 2005;82:310–311. doi: 10.1532/IJH97.E0505. [ DOI ] [ PubMed ] [ Google Scholar ]
• 9. Severe anemia: a case report. MacićDžanković A &Šubo A. https://www.jhsci.ba/ojs/index.php/jhsci/article/view/52 J Health Sci. 2011;1:110–114. [ Google Scholar ]
• 10. Severe folate-deficiency pancytopenia. Clarke V, Weston-Smith S. BMJ Case Rep. 2010;2010:0. doi: 10.1136/bcr.03.2010.2851. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 11. Severe microcytic anemia with megaloblastic changes in the bone marrow. A hematological paradoxon?. (Article in German) Reibke R, Hausmann A, Cnossen J, Hiddemann W, Spiekermann K, Braess J. Internist (Berl) 2009;50:881–886. doi: 10.1007/s00108-008-2282-x. [ DOI ] [ PubMed ] [ Google Scholar ]
• 12. Coronary haemodynamic studies in chronic severe anaemia. Bhatia ML, Manchanda SC, Roy SB. Br Heart J. 1969;31:365–374. doi: 10.1136/hrt.31.3.365. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
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• History of Present Illness

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Anemia in a 42-year-old woman

• General : Patient says she felt fine until about 2 months ago when she had "the flu," which she describes as a low-grade fever, diffuse joint pain, malaise, and a non-pruritic rash primarily over her extremities. She took acetaminophen and her symptoms resolved after 4 days. Except for her fatigue and dyspnea, she has since felt well with normal appetite and no fever or chills.
• Skin : No rash or lesions noted.
• HEENT : Denies pain or swelling in her neck, no nasal discharge or bleeding.
• Pulmonary : Dyspnea climbing stairs, worsening over the past 3 weeks to the point that she cannot climb a flight of steps without pausing to rest. No cough or wheezing.
• Cardiovascular : No exertional chest pain, palpitations, orthopnea, or paroxysmal nocturnal dyspnea.
• Gastrointestinal : No nausea, vomiting, diarrhea or abdominal pain.
• Genitourinary : Menses normal, last period 2 weeks prior, normal amount of bleeding for her. No other vaginal bleeding. Urination normal, no visible blood.
• Musculoskeletal : No swelling or pain in joints or extremities.
• Neurologic : Unremarkable
• Psychiatric : Unremarkable

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Chapter 6-1:  Approach to the Patient with Anemia - Case 1

Jeremy Smith

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Chief complaint, constructing a differential diagnosis.

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Mrs. A is a 48-year-old white woman who has had fatigue for 2 months due to anemia.

Figure 6-1.

Diagnostic approach: anemia.

Anemia can occur in isolation, or as a consequence of a process causing pancytopenia, the reduction of all 3 cell lines (white blood cells [WBCs], platelets, and red blood cells [RBCs]). This chapter focuses on the approach to isolated anemia, although a brief list of causes of pancytopenia appears in Figure 6-1 . The first step in determining the cause of anemia is to identify the general mechanism of the anemia and organize the mechanisms using a pathophysiologic framework:

Acute blood loss: this is generally clinically obvious.

Underproduction of RBCs by the bone marrow; chronic blood loss is included in this category because it leads to iron deficiency, which ultimately results in underproduction.

Increased destruction of RBCs, called hemolysis.

Signs of acute blood loss

Hypotension

Tachycardia

Large ecchymoses

Symptoms of acute blood loss

Hematemesis

Rectal bleeding

Vaginal bleeding

After excluding acute blood loss, the next pivotal step is to distinguish underproduction from hemolysis by checking the reticulocyte count:

Low or normal reticulocyte counts are seen in underproduction anemias.

High reticulocyte counts occur when the bone marrow is responding normally to blood loss; hemolysis; or replacement of iron, vitamin B 12 , or folate.

Reticulocyte measures include:

The reticulocyte count: the percentage of circulating RBCs that are reticulocytes (normally 0.5–1.5%).

The absolute reticulocyte count; the number of reticulocytes actually circulating, normally 25,000–75,000/mcL (multiply the percentage of reticulocytes by the total number of RBCs).

The reticulocyte production index (RPI)

Corrects the reticulocyte count for the degree of anemia and for the prolonged peripheral maturation of reticulocytes that occurs in anemia.

Normally, the first 3–3.5 days of reticulocyte maturation occurs in the bone marrow and the last 24 hours in the peripheral blood.

When the bone marrow is stimulated, reticulocytes are released prematurely, leading to longer maturation times in the periphery, and larger numbers of reticulocytes are present at any given time.

For an HCT of 25%, the peripheral blood maturation time is 2 days, and for an HCT of 15%, it is 2.5 days; the value of 2 is generally used in the RPI calculation.

The normal RPI is about 1.0.

However, in patients with anemia, RPI < 2.0 indicates underproduction; RPI > 2.0 indicates hemolysis or an adequate bone marrow response to acute blood loss or replacement of iron or vitamins.

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