1. Tanni- Presenter Victor- Team Leader Asma- Editor Sarwar- Timekeeper
Hematology Case 2:
Woman with Dyspnea and Fatigue
Submission date: Monday, June 16, 2014
Tanni- Presenter
Victor- Team Leader
Asma- Editor
Sarwar- Timekeeper

2. Hematology Case 2 Overview
History
Physical Examination
Lab Investigations: results and interpretation
Assessment: DDx and most likely Dx
Management
Prognosis and Patient education

3. History
67 year old female with shortness of breath on exertion, easy fatigability, and lack of energy for the past 2 to 3 months.
Denies GI, or vaginal bleeding. Denies hemoptysis. Described a good diet but variable appetite.

4. Additional Relevant History Questions
What is her PMHx?
What is her family history?
Is she currently on any medications (OTCs, Herbal included)?
What is her alcohol intake? Smoker?
Is there any chest pain?
Any symptoms of jaundice or dark coloured urine?
Any sudden weight loss?
Any recent trauma?

5. Physical Exam
Skin pallor noted. The rest of the physical examination is unremarkable.

6. Laboratory Investigations
RBC 3.72 x 1012/L
Hgb 58 g/L
Hct 0.208
MCV 56.1 fL
MCHC 285 g/L
RDW 0.204
WBC 5.8 x 109/L
Neutrophils 82 %
Lymphocytes 13 %
Monocytes 1 %
Eosinophils 4 %
Basophils 0 %
Platelets 387 x 109/L
serum ferritin <10 µg/L
serum iron 4.5 µmol/L
TIBC µmol/L
transferrin saturation 4 %
Fecal occult blood negative
Blood smear analysis
RBC morphology
1+ anisocytosis 2+ elliptocytes and target cells
2+ hypochromasia 2+ microcytosis
WBC morphology normal
Platelet morphology normal

7. Interpretation of Lab Results (key findings)
Low RBC , Hgb and Hct levels ( RBC < 4.0 x 1012/L , Hgb < 120 g/L, Hct < 37%) => Anemia
MCV of 56.1 fl => Microcytosis (<80 fl)
MCHC of 285 g/L => Hypochromia (<327 g/L)
So far, this is Microcytic Hypochromic Anemia
Low ferritin ( < 45 µg/L), High TIBC ( > 66 µmol/L) and RDW (> 15%)=> Iron Deficiency
Transferrin saturation of 4% doesn’t fit the pattern of Iron Deficiency (should be increased above 12-45% for females
High level of neutrophils (> 73%), low lymphocyte level (< 20%) and low monocyte level (< 2%) are non-specific findings at this stage

8. Differential Diagnosis with brief explanation of rationale
Microcytic Hypochromic Anemia (Iron Deficiency Anemia)
Anemia of Chronic Disease
Renal failure
Liver Disease
Neoplasia carcinoma
Leukemia

9. Most Likely Diagnosis with brief explanation of rationale
Iron Deficiency anemia
It is a type of Microcytic Hypochromic Anemia.
Rationale
Microcytosis, hypochromasia.
Presence of the target cells
Absence of any blood loss and negative FOBT
Low serum Iron, Low ferritin and high iron binding capacity.
Absence of inflammation or any comorbid conditions.

10. Pathophysiology Categories Etiologies iron deficient
impaired Hb production
Etiologies
GI blood loss
Menstrual blood loss
Decreased iron absorption
Hemolysis (less common)

11. Management Non Pharmacological Choices:
Dietary Iron -foods rich in heme iron
Promoter: Vitamin C
Inhibitor: Tea, Coffee
Pharmacological Choices:
oral iron supplements (ferrous gluconate, ferrous sulfate, ferrous fumarate)
Paranteral Iron

12. Prognosis/Patient Education
Iron Deficiency Anemia has a good prognosis if treated properly with iron supplementation.
Patient Education: iron-deficiency is when there is an insufficient amount of iron in the body. Iron is required to bind oxygen to hemoglobin which carries it to the body tissues.
Signs and Symptoms: Dyspnea, fatigue, pale coloration of the skin.
Prevention: Prevented by proper intake of iron in the diet. Diet should include meat, green leafy vegetables, enriches breads/grains, fruits. Iron absorption is increased when taken with Vitamin C and decreased when taken with caffeinated drinks.

13. References
1) Beers M., Berkow R., “Overview of Anemia”, The Merck Manual of Diagnosis and Therapy, 17th Ed., New Jersey, pp 561
2) Harper J., “Iron Deficiency Anemia”, Medscape, Retrieved on June 11, 2014,
3) “Causes and Diagnosis of Iron Deficiency Anemia in the Adult”, UpToDate, Retrieved on June 11, 2014,
4) Lee M ., “Hematology Red and White Blood Cell Tests”, Basic Skills in Interpreting Laboratory Data, 5th Edition, Ch. 15, pp