Case Study 1
Ms. A most likely has, based on the circumstances and her preliminary workup, iron deficiency anemia (IDA) due to internal bleeding from overuse of aspirin, secondary to possible rheumatoid arthritis (RA). Despite her age, RA, usually considered an age-related condition, is still possible in younger women and also is more prevalent in women than in men – 73% versus 38%, respectively (Victor, 2012) and relates to her description of “stiffness in her joints” (Mayo Clinic Staff, 2016). Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) have long been known as culprits in causing internal bleeding due to their antiplatelet activity, particularly in the gastrointestinal (GI) tract (Wedro, 2016), and Ms. A’s symptoms match those of the lightheadedness, shortness of breath (SOB), and low blood pressure associated with intra-abdominal bleeding (Wedro).

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Ms. A’s “menorrhagia and dysmenorrheal [sic]” which have been a self-proclaimed “problem for 10-12 years,” most likely since she began menstruating, is a bit more problematic in terms of causality and effect, leading to a kind of chicken-or-the-egg dilemma, for, although IDA is possible in “a few young women with extremely heavy menstrual periods” (Wilson, 2016), aspirin itself may be the cause of the heavy menstrual bleeding (CDC, 2015); or, conversely, she may have had an initially excessive menses, took high doses of aspirin for it and continued to do so, continually exacerbating the problem from the beginning and ever since.

Addressing her IDA, her lab results of a Hemoglobin of 8 g/dl, Hematocrit of 32%, and Reticulocyte count of 1.5% in particular represent the low red blood cell (RBC) count and low hemoglobin levels associated with anemia, as does her reported low levels of energy and enthusiasm (Wilson, 2016). Although these same results could also be indicative of normocytic anemia secondary to aspirin use for RA where, in one case, the lab results came back for another patient of a Hemoglobin of 11 g/dl, Hematocrit of 33%, and a Reticulocyte count of 1.0% (Brill and Baumgardner, 2000); however, the giveaway here is Ms. A’s RBC smear that showed microcytic and hypochromic cells. Microcytic hypochromic RBCs are the hallmark of IDA (Wilson) and, along with her other lab results, what can determine a differential diagnosis for her.

The lower oxygen content of the air attributable to the altitude of the high, mountainous course on which was golfing today may have been a contributing factor that helped to exacerbate her already underlying condition, but it was by no means the sole reason for it. Ms. A most likely would have still become symptomatic at some point, if not today, then at some point in the near future.

Treatment options for Ms. A include, first and foremost, discontinuation of the offending agent at the heart of her problem, aspirin, and the recommendation to instead take a non-aspirin, non-NSAID analgesic such as acetaminophen (Tylenol) for the “stiffness in her joints” (Wedro, 2016). Next, her iron intake needs to be increased in some fashion. This can be accomplished by either adding more meat and eggs to her diet, or by her taking an iron supplement, with care taken to use chelated iron or liver tablets, as most regular iron supplements can be hard on the intestines and often cause constipation (Wilson, 2016).

In summary, Ms. A most likely has IDA due to aspirin-induced GI bleeding, secondary to possible RA; circumstances and preliminary lab workup support this diagnosis. Treatment should consist of discontinuation of aspirin, recommendation of acetaminophen instead, and an increase in her iron intake, either through diet or a non-GI irritating, non-constipation causing iron supplement. Additional treatment, if any, would be warranted depending upon additional lab results, and follow-up with the patient, including follow-up bloodwork should be performed in four to six weeks.

    References
  • Brill, J. R., & Baumgardner, D.J. (2000). Normocytic anemia. American Family Physician.
    Retrieved from http://www.aafp.org/afp/2000/1115/p2255.html
  • CDC (Centers for Disease Control and Prevention) (2015). Blood disorders in women: Heavy
    menstrual bleeding. Retrieved from
    http://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
  • Mayo Clinic Staff. (2016). Rheumatoid arthritis. Retrieved from
    http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms causes/dxc-20197390
  • Victor, J. U. (2012). Possible causes of anemia in a patient with rheumatoid arthritis. Ternopil
    State Medical University, Ukraine. Retrieved from
    http://www.slideshare.net/bizkyflavour/possible-causes-of-anemia-in-a-patient with-rheumatoid
  • Wedro, B. (2016). Internal bleeding. MedicineNet.com. Retrieved from
    http://www.medicinenet.com/internal_bleeding/page3.htm
  • Wilson, L. (2016). Anemia and other blood disorders. The Center for Development.
    Retrieved from http://drlwilson.com/ARTICLES/ANEMIA.htm