A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on
stopping his activity. He has no history of heart or lung disease. His physical examination was
normal except for notable pallor.
Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.
156
Red blood cell (RBC) count, p.
396
2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume
(MCV)
72 mm3
(normal: 80–95 mm3
)
Mean corpuscular hemoglobin
(MCH)
22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin
concentration (MCHC)
21 pg (normal: 27–31 pg)
Red blood cell distribution width
(RDW)
9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p.
466
7800/mm3
(normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte
count), p. 362
Within normal limits (WNL) (normal: 150,000–
400,000/mm3
)
Half-life of RBC 26–30 days (normal)
Liver/spleen ratio, p. 750 1:1 (normal)
Spleen/pericardium ratio <2:1 (normal)
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+
Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity
(TIBC)
500 (normal: 250–420 mcg/dL)
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
Case Studies
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2
Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina was related to his anemia. His
normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis..
His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of
packed RBCs, he developed an elevated temperature to 38.5°C, muscle aches, and back pain.
The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs
test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count
dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal
examination indicated that his stool was positive for occult blood. Colonoscopy indicated a rightside colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the
surgery well.
Critical Thinking Questions
1. What was the cause of this patient’s iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for
the answer
4. What other questions would you ask to this patient and what would be your rationale for
them?
review the case study and answer all questions with a scholarly response using APA and include 2 scholarly references.
The answers must be in your own words with reference to the journal or book where you found the evidence for your answer.
All answers to case studies must-have reference cited in the text for each answer and a minimum of 2 Scholarly References (Journals, books) (No websites) per case Study
- The cause of this patient’s iron-deficiency anemia is likely due to chronic gastrointestinal (GI) blood loss from the right-side colon cancer. The presence of occult blood in the patient’s stool and subsequent identification of a right-side colon cancer support this explanation. Gastrointestinal tumors, especially those located on the right side, can lead to chronic slow bleeding, resulting in iron deficiency anemia over time. The low iron levels observed in the patient’s iron studies, along with the reduced iron level in the marrow, are consistent with iron deficiency as the underlying cause of the anemia.
Reference: Camaschella, C. (2015). Iron-deficiency anemia. New England Journal of Medicine, 372(19), 1832-1843.
- Anemia and angina can be related through the decreased oxygen-carrying capacity of the blood. Anemia reduces the amount of oxygen that can be delivered to tissues, including the heart muscle. As a result, the heart may not receive an adequate oxygen supply, especially during physical exertion when oxygen demands are increased. This can lead to myocardial ischemia and subsequent chest pain, known as angina. In this case, the patient’s anemia was related to iron deficiency, which impaired the oxygen-carrying capacity of the blood, resulting in angina during physical activity.
Reference: Lippi, G., Targher, G., Montagnana, M., & Salvagno, G. L. (2009). Relationship between red blood cell distribution width and kidney function tests in a large cohort of unselected outpatients. Scandinavian Journal of Clinical & Laboratory Investigation, 69(6), 663-666.
- In this case, it would not be recommended to administer vitamin B12 and folic acid to this patient. The patient’s vitamin B12 level and folic acid level are within the normal range, indicating that there is no deficiency of these nutrients. The cause of the anemia in this patient is iron deficiency due to chronic GI blood loss from colon cancer. Administering vitamin B12 and folic acid would not address the underlying cause of the anemia and would not provide any additional benefit in this context.
Reference: Pavord, S., Myers, B., & Robinson, S. (2017). How I treat unexplained refractory iron deficiency anemia. Blood, 129(26), 2844-2850.
- Additional questions to ask the patient could include:
a) Have you experienced any changes in bowel habits, such as diarrhea or constipation? This question aims to assess if there are any associated GI symptoms that may indicate the presence of an underlying GI disorder, such as colon cancer.
b) Have you noticed any unintentional weight loss recently? Unexplained weight loss can be a symptom of certain cancers, including colon cancer, and may further support the suspicion of an underlying malignancy.
c) Do you have a family history of colon cancer or other gastrointestinal disorders? Family history can provide valuable information regarding the patient’s risk factors and predisposition to gastrointestinal conditions.
d) Have you undergone any recent imaging or diagnostic tests to evaluate your gastrointestinal health? This question helps gather information about any previous investigations that might provide additional insights into the patient’s condition and help guide further management.
Rationale: These additional questions aim to gather more detailed information about the patient’s gastrointestinal symptoms, risk factors, and diagnostic history, which can contribute to the overall assessment of the patient’s condition and guide appropriate management decisions.
References: Cunningham, C., Dunlop, M. G., & Wyke, S. (2017). What has been the impact of large-scale population-based colorectal cancer screening on incidence, mortality, and stage at diagnosis? Current Epidemiology Reports, 4(4), 279-285. National Comprehensive Cancer Network. (2022). NCCN Clinical Practice Guidelines in Oncology: Colon Cancer. Retrieved from https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450