A 72-year-old man developed chest pain whenever he was physically active. : Nursing Class Essays

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition

Iron-Deficiency Anemia

Case Study

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 mm 3 (normal: 80–95 mm

3 )

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/mm 3 (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/mm 3 )

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

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/mm 3

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 right-

side 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?