MK OLeary

NUTR311
Anemia Lab
Anemia Calculations
1.
a. MCV = (36x10)/4.3
= 83.7 fL
b. MCH = (12x10)/4.3
= 27.9 pg
c. MCHC = 12/36
= 33%
This woman has normal levels across the board. Her RBC volume,
amount of hemoglobin in RBCs, and average concentration of
hemoglobin in average cells are all normal; therefore, she is getting
sufficient iron, B12, and folate and is neither iron deficiency anemic nor
megoblastic anemic.
2.
a. MCV = (36x10)/5
= 72 fL
b. MCH = (11x10)/5
=22 pg
c. MCHC = 11/36
= 30.6%
This womans levels are all below normal. Her MCV is low, meaning
RBC volume is low. The low MCH means thats there is a low amount of
hemoglobin in the RBCs as well. Lastly, her MCHC is low, meaning the
average concentration of hemoglobin in average red cells is low. All
results suggest that she is iron deficient anemic.

3.
a. MCV = (38x10)/3.1
= 122.6 fL
b. MCH = (13x10)/3.1
= 41.9 pg
c. MCHC = 13/38
= 34%
This womans has megoblastic anemia; her RBCs are lower than
normal; however, the RBCs that she does have are too big. This occurs
due to issues during DNA synthesis causing the RBCs to remain in their
immature state, which is bigger and not as efficient. Her MCV is high,
as the size of the RBCs are big; therefore, they have a greater volume.
Her MCH is high, as the size of the RBCs allow for a larger amount of
hemoglobin inside them. Lastly, her MCHC is normal because her blood
still has the capacity to carry oxygen and a normal volume of RBC;
proving that her anemia is not due to iron deficiency. She is anemic
due to B12 and folate deficiency.
4. TS = 50/350 x 100
= 14.3
This number gives her iron status. It is lower than normal; therefore,
she is deficient in iron, as only a small portion of transferrin is carrying
iron. The TIBC represents how much iron can be bound to blood
proteins in order to be carried. This is high, meaning there is a capacity
to bind the iron; therefore, we know that iron deficiency is the problem.
Case Study 1
1. In 2008, NHANES reported that 16% of women of childbearing
age were iron deficiency anemic. A major risk factor for iron
deficiency anemia for premenopausal women in the US is low
intake of iron, as we have very few sources of iron in the

American diet. Moreover, most of the iron that we do eat is the

non-heme form and therefore, not absorbed well.
2. The signs and symptoms of iron deficiency that this patient
exhibited are a lack of energy and feeling fatigued, constantly
feeling cold, difficulty focusing, and pale skin. Lack of energy and
feeling fatigued is a result of her not getting enough oxygen
because she does not have enough red blood cells. Also, the
brain is responsible for sleep cycles and telling your body when
you are awake or asleep; therefore, if she has low iron, her brain
function will be reduced throwing this off. She constantly feels
cold, which is also due to lack of oxygen in her blood. Oxygen is
required to make ATP; therefore, if she is low in oxygen, she will
not make as much ATP, whos byproduct is heat, thus she will
feel cold often. Lastly, iron is involved in making enzymes that
are involved in neurotransmitter synthesis; therefore, a lack of
iron can cause issues with focusing.

3. The diagnosis of iron deficiency anemia was confirmed in this

patient by the blood test results. The serum iron was low;
however, the other results confirm that iron is the issue as well.
She is more than 11g/dL below normal hemoglobin levels. Her
hematocrit, MCV, serum ferritin, and serum iron are all low; while
her TIBC is higher than normal levels. The severely low
hemoglobin shows that her blood has very little capacity to carry
oxygen and confirms that she is iron deficiency anemic. The low
hematocrit and MCV show that she has a low volume of RBCs in
her blood; her count in low as well as the size. Ferritin binds to
iron in the blood; therefore, low iron results in low ferritin, hence
her low serum ferritin. Lastly, her TIBC is high because she has

the capacity to bind iron to blood proteins; therefore, we know

that iron is the issue, as non-anemic blood would have a lower
capacity, as the iron-carrying proteins would already be loaded.
4. The diet history questions that should be asked of patients
suspected of iron deficiency are:

Has your appetite or weight decreased?

iron)
Are you now or have you ever been a vegetarian/vegan?
In a typical week, how often do you consumer foods with

(Symptom of low

vitamin C, such as cruciferous vegetables, tomatoes, citrus fruits,

sweet potatoes, etc.? (Vitamin C aids in iron absorption.)

In a typical week, how often do you consume red meat, fortified

cereals, beans, legumes, etc.?

Do you take any vitamin supplements?
How often do you consume dairy? Do you take calcium
supplements or antacids like Tums? (Calcium and iron compete
and calcium inhibits iron absorption.)

I would counsel this patient to improve dietary iron intake and

absorption by:

Eating lean red meat, fortified cereals, beans, legumes

Increasing intake of vitamin C through citrus fruits,

cruciferous vegetables, tomatoes, sweet potatoes, etc.

Not eating dairy products and iron at the same time

5. Iron deficiency should be treated through diet change and if that

is not attainable or the patients situation is severe with very low
stores and/or the problem is likely to persist, a supplement for
iron and vitamin C should be taken daily.
Case Study 2

Presentation
During a checkup for hypertension, a 65-year-old female reports a 2month history of tiredness, feeling faint from getting up too fast, and
memory problems.
Case Study Question
Do any of the presenting complaints raise your index of suspicion
about a possible vitamin B12 deficiency? If so, why?
Yes, complaining about being tired and loss of memory raise suspicion
about a possible vitamin B12 deficiency, because these symptoms
would result from being anemic. She does not have adequate B12;
therefore, folate cannot be synthesized. It seems as if not enough
oxygen is getting to her tissues, thus she is feeling tired and faint from
getting up too fast. These symptoms would most likely occur first, as
the body will sacrifice the tissues needs in order to provide oxygen for
the brain; however, eventually, the brains oxygen will also reduce,
leading to improper function and causing her to have memory
problems. Also, low B12 also results in non-myelinated sheaths around
her nerves, which aids in brain function; therefore, this could also
result in memory problems.
History
On review of systems, she reports difficulty concentrating, fatigue,
feeling faint when she stands quickly, and vague gastrointestinal
discomfort with some decrease in appetite.
She denies any history of previous trauma, diplopia, dysphagia,
vertigo, vision loss, loss of consciousness, back pain, or symptoms of
bowel or bladder dysfunction.

Her family history is negative for neurologic, psychiatric, and

autoimmune diseases. Her medications include an antihypertensive, as
well as an occasional anti-inflammatory drug for episodic headaches.
Her social history reveals a single woman who smokes about one-half
pack of cigarettes per day, drinks alcohol only socially, and denies illicit
drug use. She has a high school education and, until recently, had
worked in the office of a trucking company. Her food choice is typical
American.
Case Study Question
What risk factors does this woman appear to have for a vitamin B12
deficiency?
This woman is 65, so age could be a factor in whether or not she is
getting enough B12. Older people may not cook as much or even eat
as much; therefore, their sources of B12 could be somewhat limited.
Her age could also cause issues with intrinsic factor, as when you are
older, you have fewer stomach lining cells to make intrinsic factor,
which would also be affecting her absorption. She also has lost her
appetite, which is a sign of B12 deficiency. The medications she is
taking have been known to decrease hemoglobin in the blood, but this
wouldnt necessarily be related to B12 deficiency.
Physical Examination
Pale 65 y.o. WF who appears well-nourished, alert, and oriented.
The general physical examination is unremarkable except for
orthostatic hypotension and a weight loss of 3 pounds since her last
visit 6 months ago. She is alert and oriented times three. Her MiniMental Status Exam score is 26 out of 30. She misses one point on
serial 7s and is able to recall three of three items. Reflexes are good.
Neurological and motor exams are both normal.

Case Study Questions

Does the fact that she appears to be well-nourished indicate she is
unlikely to have a vitamin deficiency? Why or why not?
No, appearing well- nourished does not mean she is unlikely to have
a vitamin deficiency. Someone can be eating a lot and still not getting
all their vitamins. We would not know whether or not she was well
nourished unless she had completed a food log. Also, the
gastrointestinal discomfort could mean she is having some issues
absorbing or problems in general within the GI tract.
Are there any aspects of her physical examination that suggest a
vitamin B12 deficiency? Why is someone her age at risk for B12
deficiency?
Yes, she is pale, a sign that she may be anemic and does not have
enough healthy red blood cells. This may be due to vitamin B12
deficiency, resulting in a low red blood cell count. Also, someone at her
age is at risk for vitamin B12 deficiency because, as you get older, you
have fewer stomach cells to make intrinsic factor, which allows for
absorption. If she has fewer stomach cells, she will have less intrinsic
factor, and will absorb less B12. There is also less acid in the stomachs
of the elderly, so digesting foods that are bound to B12 can be
problematic. Aside from age causing decreased intrinsic factor, it could
be causing less regeneration of cells. This could result in a problem
with the receptors of the terminal ileum; therefore, more decreased
absorption Lastly, older people tend to eat less, cook less, and have
decreased diet quality, putting them at risk for B12 deficiency. She has
also lost weight; therefore, her loss of appetite could also mean she is
deficient.


Laboratory Studies
Results from the CBC and smear reveal a borderline macrocytic
anemia. The chemistry panel is within normal limits. The serum vitamin
B12 level is 215 picograms per milliliter (pg/mL). This level is
considered within a normal range by some laboratories. Her MMA is
greater than 0.5 mol/L (normal is <0.5), and her Hcy is greater than
17mol/L (normal is usually <13).
Management
She gets IM cyanocobalamin 1,000 micrograms (g) two times per
week for 2 weeks and then switches to oral vitamin B12 1,000 g daily
thereafter. Almost immediately after the initiation of injections, she
reports improved concentration. Within 2 weeks, she notes less fatigue
and normal appetite.
Case Study Questions
Why is the B12 given as IM injection initially?
The B12 IM injection is given initially because it gets results the fastest
and can fix the absorption problem. The shot will allow her body to
produce red blood cells most efficiently. She needs it intramuscularly to
bypass the absorption issue and replete stores in her liver.
Why is she administered such a high oral dose for life?
At her age, we assume that B12 deficiency will be a continuous
problem. A small amount of B12 will be absorbed through diffusion in
the stomach and if she has an absorption problem, she could get her
B12 orally at a high dosage. Also, this is less time consuming and more
cost efficient.
Why is Schillings test unlikely to be hugely informative in this case?

The Schillings test only tells us if it is an intrinsic factor problem. If

there are no changes in the two stages, wed know it was something
else; however, in this situation, we already know that it is an intrinsic
factor issue, so the test would be irrelevant.
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______ I revised the assignment at least once.
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______ I have tried hard to do my best work on this assignment.