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Introduction
A case of a female patient with the symptoms of anemia will be discussed in this paper. There are many anemia types, including iron deficiency, vitamin B12 deficiency, aplastic, hemolytic, and chronic disease. It is expected to evaluate each symptom and laboratory test to understand what type of anemia bothers the patient.
Circumstances and Preliminary Workup
In the case study, the patient is a 26-year-old woman whose primary complaints are increased shortness of breath, a low energy level, and a lack of enthusiasm. After she had become light-headed during a golf game, she was taken to the nearest ED. During a physical examination, the woman looks normal. Her temperature is 98 F. Her heart rate, respiratory rate, and blood pressure are low. The laboratory results prove a low level of hemoglobin (8 g/dl), hematocrit (32%), and erythrocyte count (3.1). RBC detects the presence of microcytic and hypochromic cells. Her past medical history includes significant problems during her menses, including menorrhagia and dysmenorrhea for the last 10-12 years. Aspirin (1,000 mg every 3-4 hours during menstruation) is taken regularly to reduce the level of pain and joint stiffness.
Disease
Taking into consideration such symptoms as the shortness of breath and a lack of energy, anemia turns out to be the primary diagnosis. The presence of such results as 8 g/dl of hemoglobin and 32% of hematocrit, as well as microcytic and hypochromic cells in the patients blood, a microcytic hypochromic category should be taken into consideration (Huether, McCance, & Parkinson, 2013). Such a problem as excessive bleeding (menorrhagia) during the last 12 years depletes the level of iron in the body. Regarding all these factors, it is possible to say that the patient has iron deficiency anemia (ICD-10-CM: D50.9).
Rationale
Patients with iron deficiency anemia usually have symptoms of other anemia types. Therefore, it is important to prove that this particular type is the patients disease. As a rule, the measurement of serum ferritin is required to identify the level of iron in the body (Lopez, Cacoub, Macdougall, & Peyrin-Biroulet, 2016). About 30% of women aged between 15-49 years have an iron deficiency. This patient meets these two categories. The common symptoms of iron deficiency anemia are extreme fatigue, headache, paleness, and dyspnoea (Lopez et al., 2016). The patient admits that she lacks enthusiasm and energy, meaning that the level of fatigue is extremely high. The shortness of breath (dyspnoea) is another important symptom among patients with iron deficiency anemia. Finally, Lopez et al. (2016) inform that about 1-2 mg of iron is usually lost during menses on a daily basis. The patient has a menorrhagia past and present history. Her menses are painful so that she has to take aspirin regularly to control pain. Pain may be a sign of infection in the body that also the reason for iron deficiency. The use of aspirin leads to the development of the disease because its presence in the body may result in gastrointestinal bleeding. Hemorrhage is the cause of the iron deficiency.
Conclusion
In general, the case of the patient under analysis has enough clear arguments and explanations of why iron deficiency anemia is the primary diagnosis that may be given. Fatigue, extensive menstrual bleeding, and low hemoglobin and hematocrit are the main symptoms that are observed in the woman and support the diagnosis.
References
Huether, S.E., McCance, K.L., & Parkinson, C.F. (2013). Study guide for understanding pathophysiology (5th ed.). St. Louis, MO: Elsevier Health Sciences.
Lopez, A., Cacoub, P., Macdougall, I.C., & Peyrin-Biroulet, L. (2016). Iron deficiency anemia. The Lancet, 387(10021), 907-916.
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