Case No.

Anemias

A 65-year-old woman is being seen in the clinic because of numbness in her lower legs and feet and difficulty walking. She has no other complaints. She takes a blood pressure pill, two calcium pills, and a multivitamin pill daily. Her laboratory results include RBC 3.0 106/ L, hematocrit 20%, hemoglobin 9 g/dL, and a markedly elevated MVC.

1. What type of anaemia does she have? This is a typical Vitamin B12 Anaemia as the data suggest. RBC: 3.0 x 106/ ul (NV for women: 4.2 to 5.4 million cells/mcL), hematocrit: 20 %( NV for women is 40%), haemoglobin: 9 (Women after middle age: 11.7-13.8 gm/dl). MVC is elevated. Vitamin B12 deficiency is a condition in which the body has inadequate stores of vitamin B12. This vitamin is essential for many aspects of health, including the production of red blood cells. Healthy numbers of red blood cells are critical for delivering oxygen and nutrients to the bodys cells and tissues. A deficiency of vitamin B12 can lead to vitamin B12 deficiency anemia. A mild deficiency may cause only mild, if any, symptoms. But as the anemia worsens it may causes symptoms such as in the case of yrs. old woman : weakness, tiredness or light-headedness , rapid heartbeat and breathing, pale skin, sore tongue, easy bruising or bleeding, including bleeding gums, stomach upset and weight loss, diarrhea or constipation. If the deficiency is not corrected, it can damage the nerve cells. If this happens, vitamin B12 deficiency effects may include: tingling or numbness in fingers and toes, difficulty walking, mood changes or depression, memory loss, disorientation, and dementia.

2. What is the reason for her neurologic symptoms? This is probably related to the Restless leg syndrome as manifested by of numbness in her lower legs and feet and difficulty walking. Iron deficiency is involved because every condition that produces iron deficiency, such as anemia or pregnancy, may lead to iron depletion in the brain nerve. Iron deficient cells in the brain are mixing up central nervous system signals to the legs and arms, causing the irresistible urge to move the arms and legs and creepy-crawly sensations that characterize restless legs (limbs)

syndrome. Results of the study of brains from people with restless legs syndrome (RLS) suggest that the disorder may result from inefficient processing of iron in certain brain cells. The findings provide a possible explanation for this disorder and may lead to new ways of treating the disease. The researchers found no evidence of lost or damaged cells in the RLS brains. Instead, they found that receptors which help cells absorb iron are abnormally regulated in cells that produce the nerve-signaling chemical dopamine. Restless legs syndrome is a movement disorder that causes uncomfortable sensations in the legs. It causes sensations such as creeping, crawling, and tugging inside the legs. The symptoms occur during periods of rest like watching television, attending a meeting and before sleeping at night. As a result, patient have restless legs syndrome, may feel difficulty in falling asleep and staying asleep, which leads to exhaustion and daytime tiredness. The common causes of RSL include iron deficiency, pregnancy, diabetes, rheumatoid arthritis, kidney failure, varicose veins or peripheral neuropathy (nerve damage in the hands and feet). High caffeine intake (coffee, tea, and cola beverages, chocolate) also may be related to restless legs syndrome. Although the muscles of the lower legs are affected most often, restless legs syndrome occasionally can cause symptoms in the arms as well.

3. What type of treatment would be appropriate? The discomfort of RLS is accompanied by an overwhelming urge to move the legs, which may relieve leg discomfort temporarily. Leg movement, such as walking, stretching and deep knee bends, seems to bring temporary relief. A leg massage or a warm bath also may help. Number of studies has related RLS to deficiencies of iron and dopamine. The lack of iron in the cells may cause them to malfunction, leading to the symptoms. Collaborative team effort was the management on this patients, usually the attending physicians will conduct test for iron levels in the blood if patients is suspected of RLS. Measurement of blood levels of ferritin, a protein used to store iron, because ferritin levels correlate with the symptoms of RLS.

Nurses can provide health teaching in Nutrition, such as one can benefit from eating iron rich foods such as red meat and green leafy. vegetables. Taking too much iron can lead to problems such as headaches, dizziness, low blood pressure, coma, and even death. Some patients can be helped without prescription medications by cutting down on beverages containing caffeine (coffee, tea, and cola drinks), limiting their use of alcohol, and getting a healthful amount of physical exercise. Other non-drug treatments include hot baths, massaging the legs, or applying hot or cold packs. Patients who are not helped by these treatments may be given one or more types of drugs to relieve their symptoms. One type of drug works by changing the levels of neurotransmitters in the brain. Other groups of drugs used to treat RLS include tranquilizers, painkillers, and drugs used to treat epilepsy. The doctor may have to try more than one type of medication before finding one that will work for the specific patient. Patients who have RLS because of an iron deficiency in their blood can be given iron supplements.

Case No. 2

Sickle Cell Disease

A 12-year-old boy with sickle cell disease presents in the emergency room with severe chest pain. His mother reports that he was doing well until he came down with a respiratory tract infection. She also says he insisted on playing basketball with the other boys in the neighbourhood even though he was not feeling well. 1. What is the most likely cause of pain in this boy? The child presented in emergency room probably suffering from chest pain secondary to sickle cell crisis, an emergency condition that needs to be priorities in emergency room. This is due to the damage sickle red blood cells that developed over time. Children with sickle cell disease develop severe pain in the chest, back, arms, legs, and abdomen. Most children complains of pain anywhere in the body. Sickle red blood cells in the lungs can cause severe illness with chest pain, fever, and difficulty breathing. Sickle cell disease can also cause permanent damage to the brain, heart, kidneys, liver, spleen, and bones. The severity and symptoms vary greatly from person to person, even within the same family. The simple pathophysiology of this is that Sickle cell disease causes red blood cells to form into a crescent shape, like a sickle. The sickle-shaped red blood cells break apart easily, causing anemia. Sickle red blood cells live only 10-20 days instead of the normal 120 days. The damaged sickle red

blood cells also clump together and stick to the walls of blood vessels, blocking blood flow. This can cause severe pain and permanent damage to the brain, heart, lungs, kidneys, liver, bones, and spleen. Severe pain is an emergency called acute sickle cell crisis. A person may not know what brought on the pain, but infection, dehydration are common triggers. 2. Infections and aerobic exercise that increase the levels of Deoxygenated hemoglobin produce sickling in persons who are homozygous for the sickle cell gene and have sickle cell disease, but not in persons who are heterozygous and have sickle cell trait. Explain.

3. People with sickle disease experience anemia but not iron deficiency. Explain.