Case Study 1: A 26-Year-Old Apparently Healthy Person

Case Study 1case Study 1ms A Is An Apparently Healthy 26

Ms. A, a 26-year-old woman, presents with symptoms of increased shortness of breath, low energy, and fatigue that worsen during menstruation. Her recent episodes of light-headedness and her vital signs—elevated heart and respiratory rates with low blood pressure—suggest an underlying hematologic problem that has been exacerbated during her menstrual cycle. Her history reveals chronic menorrhagia (heavy menstrual bleeding) and dysmenorrhea (painful periods), for which she regularly takes 1,000 mg of aspirin every 3 to 4 hours during her periods to manage discomfort. Additionally, she uses aspirin during the summer to reduce joint stiffness.

Laboratory findings show she is anemic, with hemoglobin at 8 g/dL, hematocrit at 32%, and an erythrocyte count of 3.1 x 10^6/mm³. The peripheral blood smear reveals microcytic (small cell size) and hypochromic (pale coloring) erythrocytes. Her reticulocyte count is slightly elevated at 1.5%, which indicates some marrow response to anemia but suggests a chronic process rather than an acute blood loss or destruction.

Analysis of Ms. A's Anemia

Given her laboratory data—microcytic, hypochromic anemia, and her clinical history—the most probable diagnosis is iron deficiency anemia (IDA). The microcytic and hypochromic appearance on blood smear are classic features of iron deficiency, as iron is essential for hemoglobin synthesis. Additionally, her history of menorrhagia is a significant contributing factor since heavy menstrual bleeding can cause chronic blood loss leading to iron depletion.

Her symptoms are worsened during menstruation, which aligns with increased blood loss during her periods. The low hemoglobin and hematocrit levels further support iron deficiency as the cause of her anemia. The elevated reticulocyte count suggests that her bone marrow responds to the anemia by producing new erythrocytes, but the ongoing iron deficiency hampers the production of healthy, hemoglobin-rich red cells. This impairment results in the persistent microcytic, hypochromic cells observed in her blood smear.

Her use of aspirin, a medication known to cause gastric mucosal irritation and gastrointestinal bleeding, may exacerbate her iron deficiency, but the primary cause remains the chronic blood loss from menorrhagia. Aspirin's role is more of an aggravating factor rather than a primary etiologic agent in her anemia. Moreover, her symptoms of fatigue and dyspnea are typical manifestations of anemia resulting from inadequate oxygen-carrying capacity of the blood.

Pathophysiology and rationale

Iron deficiency anemia develops when iron intake or absorption is insufficient to meet the needs of erythropoiesis, or when iron losses exceed intake. In Ms. A's case, her menorrhagia leads to persistent iron loss, depleting her iron stores. As iron is critical for hemoglobin synthesis in developing erythrocytes, its deficiency results in the production of smaller, less hemoglobin-rich red blood cells—characteristic features of microcytic hypochromic anemia.

The body's response to iron deficiency includes increased intestinal iron absorption and mobilization of iron stores. However, ongoing blood loss overwhelms these compensatory mechanisms, leading to decreased hemoglobin synthesis. The reticulocyte response indicates that the marrow is attempting to compensate, but without correcting the iron deficiency, this response remains insufficient to restore normal red blood cell volume and hemoglobin content.

Additional considerations

Her use of aspirin should be carefully evaluated, especially considering the risk of gastrointestinal bleeding. Blood tests such as serum ferritin, serum iron, total iron-binding capacity (TIBC), and transferrin saturation would help confirm iron deficiency. Iron supplementation and addressing the cause of menorrhagia would be essential parts of her management.

Conclusion

In summary, Ms. A's clinical presentation, hematological findings, and history strongly suggest that she has iron deficiency anemia. Her chronic menorrhagia is the most likely underlying cause, and her use of aspirin may contribute to gastrointestinal bleeding, further exacerbating her anemia. The treatment should focus on correcting iron deficiency through supplementation and investigating options to control her menorrhagia to prevent ongoing blood loss.

References

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• World Health Organization. (2011). Haemoglobin concentrations for the diagnosis of anemia and assessment of severity. WHO Global Database on Anemia.
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