Based on the clinical vignette, this patient is anemic and presents to the emergency department for symptoms relating to her condition. Based on the past medical history and the preliminary workup, one can have an idea of which type of anemia is occurring in this patient has and its underlying cause. Anemia can be divided into three categories based on the mean corpuscular volume (MCV) of the red blood cells: microcytic, normocytic, and macrocytic. In the physician’s report in the emergency room, it said that the patient’s red blood cells appeared microcytic and hypochromic. This information would lead someone to believe that the patient has a microcytic anemia. If red blood cell indices were ordered, then using Wintrobe’s classifications, the diagnosis of microcytic anemia could be confirmed (Brugnara & Mohandas, 2013).
Now that the clinician thinks that the patient has a microcytic anemia is present, they have to find the etiology of the disease. There are four primary types of microcytic anemia, iron-deficiency anemia, thalassemias, sideroblastic anemia, and anemia of chronic disease. Anemia of chronic disease occurs in patients with a long-standing illness, where the body will sequester iron to prevent a bacterial uptake of the element. This method is one of the ways that the body can fight off chronic disease symptoms. In this patient, this diagnosis seems unlikely since she stated no other medical conditions and appeared to be healthy otherwise. Iron studies can determine the amount of iron, transferrin, and ferritin in the body. If the iron was low and ferritin was high, then this would be a plausible diagnosis. Sideroblasts are ringed red blood cells that are unable to incorporate iron into the red blood cells. This type of cell would be present on a blood smear, which was negative in this patient. If the ED physician was still concerned about this diagnosis, then they could ask about any new medications, lead poisoning, or familial blood disorders that can cause this type of disease. Thalassemias are an error in the globulins subunit in hemoglobin that is common in Mediterranean and Southeast Asian populations. In this patient, this diagnosis seems unlikely, but the physician would have to ask for a family history of blood disorders. A hemoglobin electrophoresis would diagnose this condition. Iron deficiency anemia is the most likely diagnosis. This type of anemia is the most common type of microcytic anemia (Looker et al., 1997). It can be caused by decreased iron consumption or chronic bleeding.
Regarding the iron deficiency anemia, a clinician needs to figure out if it is due to a lack of iron intake or episodes of iron loss. This patient has a history of menorrhagia, which can lead to excessive blood loss. However, this patient also reports long-term aspirin use, which can be a cause of gastrointestinal bleeding (Huang et al., 2011). The physician should also ask about the patient’s nutritional status and obtain iron studies to determine if the patient has an insufficient iron intake.
A twenty-six-year-old female presented to the ED with an episode of fatigue and is found out to be anemic. The most likely diagnosis in this scenario is an iron deficiency anemia based on the lab results and patient’s history. The most likely cause of this condition is the patient’s menorrhagia. The physician should order iron studies to confirm the diagnosis of iron deficiency and rule out a GI bleed as a source of blood loss. The patient should also see her OB/GYN doctor to discuss a new treatment strategy for her abnormal menses and prevent a similar episode from reoccurring.
References
Brunara, C., Mohandas, N. (2013) Red cell indices in classification and treatment of anemias: from M.M. Wintrobes's original 1934 classification to the third millennium. Current Opinions on Hematology, 20(3):222-30. http://doi.org/10.1097/MOH.0b013e32835f5933
Huang, E. S., et al. (2011). Long term use of aspirin and the risk of gastrointestinal bleeding. The American Journal of Medicine, 124(5), 426–433. http://doi.org/10.1016/j.amjmed.2010.12.022
Looker, A.C., et al., (1997) Prevalence of iron deficiency in the United States.
