case study- group 5-sem 4

7/30/2019 Case Study- Group 5-Sem 4

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MPHA 4305 -SBT V

Case Study 5

Group 5


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Group Members:Lau Li Wenn BPM 1109 1317

Lee Suo Ying BPM 1109 1311

Lau Wai Hoong BPM 1109 1146

Lee Soo Mei BPM 1109 1044

Lee Yee Ling BPM 1109 1036Lee Ming Keat BPM 1109 1310


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Case History 1


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A 44-year-old man who had lost his job because of

absenteenism, presented to his physician complaining of

loss of appetite, fatigue, muscle weakness, and emotional

depression.

The physician examination revealed a somewhat enlarged

liver that was firm and nodular, and there was a hint of

jaundice in the sclerae and a hint of alcohol in his breath.

The initial laboratory profile included a hematologicalanalysis that showed that he had an anemia with enlarged

red blood cells (macrolytic). A bone marrow aspirate

confirmed the suspicion he had a megaloblastic anemia

because it showed a greater than normal number of redand white blood cell precursors, most of which were larger

than normal. Further analyses revealed that his serum folic

acid level was 1.2ng/mL (normal 2.5 to 20), his serum B12

level was 253 ng/mL (normal 200-900), but his serum iron

level was normal.


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Patient Background

Gender : Male

Age : 44 years old

Symptoms: loss of appetite

fatigue

muscle weakness Emotional depression


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Physical examination:

Enlarged liver (firm & nodular)

Hint ofjaundice in the sclerae Hint ofalcohol in his breath


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Initial laboratory profile

Hematological Analysis:

Anemia with enlarged RBC ( Macrocytic )

Bone Marrow Aspirate: no.RBC& WBC precursor >normal

Size LARGER than normal


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Serum level of

Folic acid : 1.2ng/mL ( normal 2.5-20 )

B12 : 253 ng/ml (normal 200-900) Iron : NORMAL


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Diagnosis:

Megablastic Anemia


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What is megaloblastic anemia?

Enlargement of the red blood cells, and thus

they are dysfunctional

Common causes are, Vitamin B12 and folic

acid deficiency results from

Malabsorption

Dietary deficiency

Gastric diseases

Liver diseases

Medication

Alcoholism


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What is the cause of megaloblastic anemia in this

patient? What is its correlation with alcoholism?

I. Deficiency of folic acid (which may cause byliver disease or alcoholism)

Liver disease:

Cell necrosis, which decreases the livers abilityto metabolize and excrete bilirubin, thusunconjugated bilirubin in the blood lead to

jaundice.

Interfere with the production and metabolism ofred blood cells, thus abnormal RBC are produced

Impairs with the absorption and also diminishhepatic storage of folic acid


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Alcoholism:

Interfere with the enterohepatic cycle

Decrease the absorption of folic acid, becauseusually alcoholism will lead to malnutrition

and thus to the deficiency of many nutrients.

Why deficiency of nutrients?

Poor diet

Intestinal malabsorptionDecrease hepatic uptake

Increase body excretion, mainly via urine


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Alcoholism Liverdisease

Folic aciddeficiency

Megaloblasticanemia

Jaundice

Failed in the

production

of normal

RBC


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Case History 2


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Patient is, a malnourished-appearing woman in

her second trimester of pregnancy, presents to

the local health clinic for her regular checkup.She is a multiparous, 22-year-old woman who

ran away from home when she was 16. She has

a 7-year history of excessive alcohol intake and

has been using cocaine frequently for 3 years.She lives with her boyfriend and her 19-month-

old daughter. During both pregnancies, T.J. lost

8 to 10 Ib during the first trimester secondary

to nausea, vomitting, and aneroxia. Her onlycomplaints are dyspnea on exertion,

palpitations, and diarrhea.


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Pertinent laboratory values include the following:

Hct, 25.5% (normal, 40 to 44%); MCV 112m3

(normal, 76 to 100); MCH, 34 pg (normal, 27 to33);RBC, 1.1 X 106 /mm3(normal, 3.5 to 5.0);

folate, 30ng/mL (normal, in RBC 140 to 960);

serum vitamin B12, 250 pg/mL (normal, 200 to

1,000); reticulocytes, 1% (normal, 0.5 to 1.5);platelets, 75,000/mm3 (normal 130,000 to

400,000); WBC count, 2,000/mm3 (normal, 3,200

to 9,800 ) with hypersegmented PMN; LDH, 450

U/L (normal, 50 to 150); and bilirubin, 1.5 mg/dl.

Normal, 0.1 to 1).


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Patient Background

Name : T.J. Gender: Female

Age : 22 years old

Malnourished-appearing

Stage of pregnancy : 2nd trimester

Has 19-month-old daughter

Excessive alcohol intake ( 7 years)

Cocaine administration (3 years)


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In both pregnancies:

lost 8-10 Ib in 1st trimester (Nausea,

vommitting & anorexia)

Symptoms:

Dsypnea on exertion, palpitations &

diarrhea

P i l b l


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Pertinent laboratory value:

Blood Serum level Normal Range

Hct 25.5% 40-44% Less

RBC 1.1 X 106 /mm3 3.5-5.0 /mm3 Less

Folate 30 ng/mL 140-960 ng/mL Less

Platelets 75,000 /mm3 130,000-400,000/mm3 Less

WBC(Hypersegmented

polymorphonuclear

leukocytes)

2,000/mm3

3,200-9,800 /mm3

Less

MCV 112 m3 76-100 m3 Greater

MCH 34 pg 27-33 pg Greater

LDH 450 U/L 50-150 U/L Greater

Vitamin B12 250 pg/mL 200-1000 pg/mL Normal

Recticulocytes 1% 0.5-1.5% Normal


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Diagnosis?


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Question 1:

T.J is not taking any presciption

medications. What factors make T.J. at

risk for folate deficiency???


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1. Pregnancy

Increased need for folic acidRequire more folate to meet the needs of her

developing baby.

If she dont have sufficient folate intake, she

may become folate deficient and her unborn

baby may develop a neural tube defect.

This happens when unborn baby's nerves and

spinal cord do not develop properly in the firstmonths of pregnancy.


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2. Malnutrition

Poor dietary intake of folic acid

(does not eat enough foods that contain

folic acid)

Diets lacking of fresh fruits andvegetables, or consistently overcook food

Imbalance and unhealthy diet


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Inadequate dietary intake of folic acid

interferes with the absorption of folate.

Drinking too much alcohol can reduce T.J.

body's ability to absorb and use folate.

3. Chronic Alcoholism


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Question 2

Which laboratory values support thediagnosis of folate deficiency ? How

should T. J be treated and monitored?


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The folate concentration in the RBC is only 30ng/mL, which is much lower than the normal

range. The Vitamin B12 is at normal range.

The MCV or MCH has increased in the patients,with folate deficiency, indicates the patient

diagnosed with megaloplastic anemia. The platelets count are low, and the white blood

cells count are low with hypersegmentedpolymorphonuclear leukocytes.

Hypersegmented polymorphonuclear leukocytesare the earliest and most specific signs ofmegaloblastic anemia.


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Treatment

Oral folic acid therapy can be given,

because it is inexpensive and stable.

15mg daily for 4 months due to themalabsorption states.


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Monitoring the Condition

Around 10 days after starting treatment, the

blood test is taken to check whether the levels

has started to rise.

Approximately 8 weeks is required for anotherblood test to confirm the treatment has been

successful.

The blood test is taken again after the treatment

has finished.

C t d 3


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Case study 3

A 65-year-old woman presents to the medical out-patient

department with a history of fatigue. She has in the last few months

been undergoing adjuvant cytotoxic chemotherapy for a node-positive resected breast cancer. The patient is pale, but no other

abnormalities are noted. Her full blood count shows a haemoglobin

level of 9.8 g/dL with a mean corpuscular volume of 86 fL; other

haematological indices and serum transferrin are normal. Her faecal

occult blood is negative. She is started on oral iron sulphate andgiven weekly injections of erythropoietin 40 000 U subcutaneously.

Three months later, her haemoglobin level has risen to 13.5 g/dL,

but she presents to the Accident and Emergency Department with

acute-onset dysphasia and weakness of her right arm. Her supine

blood pressure is 198/122mmHg. Her neurological deficit resolves

over 24 hours and her blood pressure settles to 170/96 mmHg. She

has no evidence of cardiac dyshythmias or of carotid disease on

ultrasonic duplex angiography, and her serum cholesterol

concentration was 4.2 mmol/L.


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Summary Gender: woman

Age: 65 yrs old

History: fatigue

Therapy received before: adjuvant cytotoxic

chemotherapy : node-positive resected breastcancer.

Haemoglobin level: 9.8 g/dL with a mean

corpuscular volume of 86 fL

other haematological indices and serum transferrin:

normal

faecal occult blood: negative


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Treatment: oral iron sulphate & inject erythropoietin

40 000U (SC) weekly.

Haemoglobin level after 3 months: risen to 13.5 g/dL

Accident & emergency department: due to acute-

onset dysphasia and weakness of her right arm.

Supine blood pressure: 198/122mmHg.

After 24 hours, blood pressure- 170/96 mmHg,

neurological deficit resolves

Cardiac dyshythmias / carotid disease in ultrasonicduplex angiography- negative

Serum cholesterol conc.4.2 mmol/L


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Question 3

What led to this patients acute neurological episode? Does she

require further therapy?


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Question 3

The 65-year-old woman is diagnosed for a

node-positive resected breast cancer. She

had been undergoing cytotoxic

chemotherapy in the last few months.


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1) Filgrastim (granulocyte colony-stimulating

factor; G-CSF).

2) Sargramostim (granulocyte-macrophage

colony-stimulating factor; GM-CSF).

Both stimulate the production of neutrophils

and accelerate the recovery of neutrophils

after cancer chemotherapy.


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4) Oprelvekin (interleukin-11 [IL-11]) increases

the number of peripheral platelets. It is usedfor the treatment of thrombocytopenia

patients after had cancer chemotherapy.

5) It reduces the need for platelettransfusions.

Common adverse effects of IL-11 are

fatigue, headache, dizziness, and fluidretention.


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Serum cholesterol concentration= 4.2mmol/L.

Total Cholesterol [mmol/L (mg/dl)]

a) Risk indicated if greater than 4.5

b) Desirable: =240)

The first steps in treating high cholesterol

levels are regular physical activity andhealthy eating.

case study- group 5-sem 4

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