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Ms. A evidently suffers from chronic post-hemorrhagic hypochromic anemia. She deals with etiology of chronic blood loss due to abnormal menstrual periods. Blood contains red blood cells, which carry hemoglobin. Hemoglobin is a molecule that is composed of an iron caring component (hem) and a protein (globin). If a person experiences blood loss, he/she will lose iron too. Menorrhagia is a heavy menstruation at regular intervals. The World Health Organization.  reports that over 15 million women aged 30-55 years suffer from excessive menstruations. With time, the blood loss overcomes the body iron reserves and the rate of blood replenishment. For the complaints of abnormal menstruations last for a decade, this is the case of chronic blood loss. Thus, Ms. A’s case is an example of the most common type of post-hemorrhagic anemia.

The symptoms described are typical for anemia. First, the woman suffers from shortness of breath and low levels of energy and enthusiasm. These may be a sign of common fatigue do to low oxygen caring capacity. Next, the symptoms seem worse during menses. This is probably due to additional blood loss during the cycles. Third, the symptoms deteriorated while playing at a mountainous course. Barometric pressure being lower at high altitudes, the partial oxygen pressure drops. Ms. A’s red blood status apparently fails to meet the increasing needs of oxygen delivery at this condition.

The current state of condition that the attending physician met consists of tachycardia, which is a physiological response to anemia. Should oxygen delivery fall, a hyperdynamic state of blood circulation develops to compensate lower oxygen capacity.

Aspirin is a non-steroidal anti-inflammatory drug that has a strong antiplatelet effect due to its irreversible inhibition of cyclooxygenase. Once a woman takes aspirin, it usually takes five to seven days to recover the platelet-dependent hemostasis pathway to recover. Menorrhagia can be recognized when total blood loss exceeds 80 mL per cycle or menses that last more than seven days. Thus, aspirin prescribed kills pain and influences hemostasis substantially. Hemostasis challenged long-term intake of aspirin and causes iron deficient anemia.

Bleeding causes iron depletion, therefore, long-term blood losses ensue anemia. When the iron equilibrium breaks iron deficiency, anemia develops. A balance between absorption and body losses maintains iron storage. When iron concentration lowers, absorption in the intestine increases. The serum iron decreases and by a total iron-binding capacity should increase. Nevertheless, in some conditions, blood loss outstrips restoring potentials.

A red blood cell, which carries hemoglobin, has a life span of around 120 days. This is the average time when normocytes produced prior to hemorrhage are replaced by microcytes. Before this time, peripheral blood smear would preset with polymorphic population of red blood cells. However, should iron-deficient erythropoiesis start, the peripheral erythrocytes of normal size are replaced by red blood cells of a small size. This is why the laboratory studies of smear showed microcytic and hypochromic cells.

Reticulocyte count stands for the degree of effective erythropoiesis. It takes only one day for an immature red blood cell, called reticulocyte, to mature. In the setting of stress erythropoiesis, as in cases of anemia, these cells are released prematurely from bone marrow to support blood circulation.

The World Health Organization. defines anemia for an adult non pregnant women as hemoglobin less than 12.0 g/l. Anemia in the severity is categorized into three stages according to hemoglobin level: mild (Hb> 10.0g/l), moderate (7.0g/l ≤Hb< 10.0g/l), and severe. Concordantly, in this case, this is moderate anemia presented.

The patient has low hematocrit level – 32%, which has occurred because the number of red blood cells decreased. Hematocrit states a decrease of red blood cells to circulating blood volume ratio. Color index of blood is an indicator of relative concentration of hemoglobin in red blood cells. There is sufficient data to calculate color index. Color index of blood = 3 * Hb / first three figures of Er = 3*81/310 = 0.78. The color index of blood reduced, this is the state of the reduced content of hemoglobin in an erythrocyte.

Ms. A suffers from

a) hypochromic, microcytic  anemia according to morphological classification (iron deficiency anemia)

b) chronic blood loss (post-hemorrhagic) according to pathological classification

c) acquired anemia – chronic blood loss (female reproductive system)

d) moderate in severity.

Case Study #2

Medical care for congestive heart failure consists of non-pharmacologic, pharmacologic, and invasive patterns (Jessup et al., 2009). All strategies aim to limit manifestations of heart failure, providing better quality of life, and prolonging life expectancy.

Non-pharmacologic approaches include dietary sodium restriction. Although, challenged by some, fluid restriction traditionally is recommended. As long as weight gain is a hazardous symptom of fluid congestion, attention to weight gain is of paramount importance. Physical activity is not contraindicated but needs to be appropriate. Evidence based pharmacologic interventions include beta-blockers at sufficient doses to reduce sympathetic activity, ACE inhibitors, spironolactone, and probably sartans. This has not been investigated in randomized trials, but diuretics are necessary to relieve symptoms. Digoxin is effective in rate control and has some symptomatic benefits. Anticoagulants are an effective way to prevent embolic events. Inotropes may be used in severe cases. Invasive strategies depend on etiology of heart failure and include revascularization, such as coronary artery bypass grafting or percutaneous interventions, valve surgery, electrophysiologic or resynchronization therapy, and implantable cardioverters-defibrillators. Should progressive heart failure occur, the prognosis is poor, and either heart transplantation or ventricular assist device needs to be considered.

In accordance with the Guidelines for the Diagnosis and Management of Heart Failure in Adults, diuretics are recommended. This recommendation has strong ground for this patient because his state of condition is undoubtfully related to extracellular fluid (oedema) restriction. Oedema and moist crackles throughout lung fields indicate congestion. Labored breathing is most probably due to compromised left ventricle function (either contractility of reduced compliance). Furosemide may be the starting loop diuretic. Intravenous access is sometimes preferable as for the start. Aldosterone antagonists are of benefit as long as creatinine level is not severely elevated. Spironolactone may be considered. Angiotensin converting enzyme inhibitors are recommended for all patients with heart failure. Probably, because of poor compliance, he should be prescribed with long-acting remedy, not captopril. Beta-blocker, for example, carvedilol (a non-selective blocker with a-adrenoblocking potential) reduces mortality. The problem for this drug is that it needs strict discipline of intake. Carvedilol is the drug of choice, when the ejection fraction is reduced. Nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs must be withdrawn. Digoxin may reduce recurrent hospitalisations. The etiology confirmed and further studies done, an implantable cardivertor-defibrillator or resynchronization therapy to reduce mortality may be indicated.

On the other hand, one may assume that his poor condition represents the end-stage heart disease. The patient may not improve despite optimal medical therapy, and his advanced stage might be considered for mechanical circulatory support, or referral for cardiac transplantation.

Medical treatment plan consists of three parts:

1) nonfarmacologic interventions: patient’s guide from The Heart of New Jersey’s Cardiac Care insists that heart failure medicines must be taken exactly as the doctor has prescribed, the diet to follow closely, daily weighing, influenza vaccination every autumn. Smoking to be skipped, low-sodium diet, dining out menue section to avoid or the order must be kept in mind.

2) drugs: Furosemide 80 mg PO qDay, Spironolactone Initial 50 mg PO qDay, Carvedilol 3.125 mg PO q12hr for 2 weeks, then increase q2Weeks 6.25 mg, 12.5 mg and 25 mg PO q12hr, Digoxin 0.25 mg/day PO, Quinapril 5 mg PO BID. It must be noted, however, that this is a rather general scheme. For example, should ischemic heart disease be the etiology, intiplatelet (aspirin) must be added, arrhytmia (atrial fibrillation most common) anticoagulant (warfarin) is to be considered. Cholesterol and low-density lipoprotein fraction need to be checked and statins might be prescribed. The medication schedule should be written clearly in an organized fashion.

3) invasive interventions cannot be ruled out because there is no sufficient data in the task. Taking into account gender and age, one may assume that this is ischemic heart disease to manage. Thus, coronary imaging is essential, and revascularisation procedure is to be recommended. As soon as ECHO done, valvular pathology may be diagnosed, which leads to cardiac surgeon consultation. After electrocardiogram was taken, electrophysiology intervention is to be considered.

Simple teaching points may be proposed:

1) You should take all prescriptions regularly and in strong accordance to the added timetable

2) upon discharge from the hospital (assuming severe decompensation to be in hospital treated), usual activities must not fatigue, but apartment furniture must not obscure everyday walking, all spills to be kept clean so that they do not spill, arrange your light so that You do not have to walk in darkness

3) please mind Your primary care physician. This doctor will come to see how You proceed and let know if the management plan needs to be changed

4) low salt diet is of importance since this is an easy but an effective way to prevent worsening. Please weigh Yourself daily to control fluid restriction in the body.

As for the family, a guide for family caregivers proposes basics of disease management: keeping a daily log (breathing, medications, diet and activities), knowing when to call for emergency (increasing weight, shortness of urine, increasing swelling), be ready to provide the doctor important information (breathing, weight gain, fatigue). It is encouraged to do some research in the library or on the Internet about the disease.

Code: Sample20

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