Hematology Results Analysis - Case Study Example

Answers to Case History This hematology results signifies high white cell count, normal platelet count, reduction in haemoglobin level, reductionin serum iron concentration, reduction in mean corpuscular haemoglobin, and reduction in mean corpuscular volume. This picture suggests there is anemia as a result of malnutrition and probably blood loss. The picture is consistent with microcytic hypochromic anaemia. There is an associated inflammatory component of the disease suggested by leukocytosis. Since there is normal platelet count, one can freely rule out bone marrow inflammation. 2. In this setting, small-bowel involvement may lead to malabosrption. Along with this, there are anorexia and catabolic process of chronic inflammatory process of the disease. All these may combine to cause profound weight loss over a short period of time. 3. Since there is a component of malabsorption, Schilling test may be done to rule out Vit B12 deficiency. Electrolytes to rule out potassium, magnesium, and calcium deficiencies need to be done. Serum albumin would indicate hypoalbuminaemia indicating amino acid malabosrption or protein losing enteropathy. Air-contrast barium enema and CT scan need to be done to better delineate the terminal ileal involvement. Colonoscopic examination with rectal biopsy can yield the histologic nature of the disease. 4. Apart from other general measures like nothing orally, intravenous alimentation, fluid resuscitation, the medical therapy of first choice would have been sulfasalazine. This drug consists of a sulfapyridine moiety chemically bound to 5-aminosalicylate. This undergoes bacterial cleavage, the liberated sulfapyridine is absorbed, and the salicylate component exerts its anti-inflammatory action through inhibition of prostaglandin synthesis, thus reducing the inflammation. 5. The complications that may arise out of this disease, that is, Crohn's disease are intestinal obstruction; fistula formation with contiguous intestinal lumen or urinary tract; small-bowel or colonic malignancy; bile salt malabsorption leading to increased gall stones; and increased incidence of urinary tract oxalate stones. 6. If there is associated chronic inflammation of the bone marrow, there may be anemia with decrease in the platelet count. The anaemia is variable, so are the red cell indices. Megaloblastic anemia with increased MCV is rare. 7. On the basis of these preliminary tests, the diagnosis would be Crohn's disease. This disease presents in a young adult with variable weight loss, right lower quadrant discomfort or pain, and diarrhoea. The diarrhoea is usually moderate often without gross blood. The patient looked pale due to anaemia, and mouth ulcerations were due to aphthous stomatitis, which is a common accompaniment. The right lower quadrant tenderness is consistent with the mass felt per abdomen that reflected adherent loops of bowel. As expected, the blood picture reflected anaemia and leukocytosis. The final diagnosis is made from the appearance of the distal ileum that showed narrowing and thickening of the intestinal wall. 8. The main risk factor is genetic predisposition to the development of the disease. Whites and Jews have increased incidences, and increased preponderance of disease in monozygotic twins support. Exact genetic linkage yet to be discovered. 9. The other risk factors that may be involved are, immune mechanism suggested by extra-intestinal manifestations, abnormalities of cell-mediated immunity, and psychological factors caused by stress. 10. There is considerable individual variation with respect to drug metabolism, hence effects of the drug. Drug metabolism is related to cytochrome P450 family of genes. In humans, enzymes encoded by P450 genes are located in the liver where they metabolize drugs. Through oxidative metabolism, these enhance water solubility of the drug to enhance its excretion. For drugs that are metabolized in this way, this process affects the blood levels of the compound, so the therapeutic efficacy, and sometimes, this is necessary to convert an inactive prodrug to active metabolite. The individual variations of CYP450 enzyme activity, regardless of the causes, such as, genetic variations, other environmental factors, diet, concurrent medications, gender, age, overall health, hormones, hepatic disease, inflammation, nutrition, pregnancy, etc., can affect the availability of the active drug in the body. In other words, differences in P450 enzyme activity can determine whether the drug reaches the desired therapeutic level in the blood. As a result, the patients can experience profound differences in how they respond to the drug. 11. The common gastrointestinal conditions that can give rise to the above scenario are acute infectious colitis, diverticulitis, colonic or intestinal neoplasms, amoebiasis, bacillary dysentery, pseudomembranous colitis, irritable bowel syndrome, abdominal lymphoma, and nongranulomatous ulcerative jejunoileitis. Q2. 1. The most likely diagnosis is acute myocardial infarction (MI). Those patients who have a family history of heart disease, personal history of smoking, hypertension, dyslipidaemia indicated by increased cholesterol and lipoprotein with obesity and previous history of angina pectoris are prone to develop acute MI. Pain is most common presenting complaint; usually it is a heavy, squeezing, crushing pain. It is similar in character to the discomfort of anginal pectoris, but usually is more severe and lasts longer. The pain may start at rest and may radiate to the arm and neck. It is often accompanied by profound weakness, nausea, vomiting, and sweating. This picture is consistent with the diagnosis of MI. 2. The main risk factor predisposing to this disease is dyslipidaemia leading to abnormal increase of lipoproteins in the blood. These lipoproteins get deposited in the tunica media of the coronary arteries thereby reducing the cross-sectional lumen of the artery. In a smaller artery, this may lead to reduction of the blood flow to a specific area of the myocardium. With exertion when the myocardial oxygen demand increases, the area where the lipoprotein accumulation happens, the area of atherosclerotic narrowing or plaque build-up may rupture and thrombus formation happens. This leads to total occlusion of the arterial lumen, and blood flow distal to the area of the thrombus formation ceases leading to myocardial oxygen deprivation and death of the tissue, and this is called as MI. 3. The patient had a similar but less severe condition associated with walking. The exercise related to walking. This is suggestive of angina pectoris, which occurs usually as a result of exertion in patients with atherosclerotic cardiovascular disease. What happens is with exertion, when there is increased activity of the heart, the myocardial oxygen demand increases. If any particular area of the myocardium is supplied by a narrowed and diseased artery, that area of the myocardium suffers from relative deficiency of blood supply as required by the extent of exertion. This indicates the occlusion by the atherosclerotic plaque is moderate so that it has no effect on blood flow to that particular area at rest. Usually this pain is similar but less severe not accompanied by nausea, vomiting, or sweating, and it abates at rest. The earlier condition is related to the present presentation, since those patients who have atherosclerotic coronary artery disease have angina as warning symptoms. The anginal status continues for a time and if the risk factors are not modified by lifestyle adjustments, these patients are prone to develop MI, how we have explained earlier. 4. The risk factors related to development of myocardial infarction are obesity, hyperlipidaemia, smoking, genetic factors, diet, sedentary habit, hypertension, high salt intake, alcoholic intake, stress, and diabetes. Obesity is the result of high-fat diet that increases lipid deposition in a person having disorders of lipid metabolism and sedentary habit. This would lead to atherosclerosis. Hypertension that is contributed to by salt intake, diabetes, smoking, stress, and diet can lead to a plaque rupture, thus causing an acute MI. Genetic predisposition usually hints to a family history. 5. The treatment of MI consists of antithrombotic agent since thrombosis in arterial lumen has been demonstrated to be the cause of MI. This is accomplished by antiplatelet agents and antithrombin therapy. The standard antithrombin therapy is heparin. The other non-fibrin antithrombotic therapy is streptokinase. Most clinicians use immediate heparin bolus, aspirin, and tPA (tissue pasminogen activator). The most important factor that needs to be considered is the risk of bleeding. While maintenance heparin therapy continues, the bleeding risk is monitored by activated partial thromboplastin time. 6. What can be the other investigative approach to deliver a definitive therapy Even if MI is diagnosed on the clinical grounds, the localization of the artery is important. This is done by cardiac catheterization or coronary angiography. 7. Is there any intervention possible while doing an angiography Yes after the artery is localised and demonstrated to have the culprit occlusive lesion, the doctor may decide to a percutaneous transluminal coronary angioplasty by balloon inflations through the catheter guidewire or if the occlusion is stubborn, he may decide to leave a metal lattice stent impregnated with drugs at the site of occlusion. 8. What are the lifestyle modification advices usually given to these patients Smoking cessation, dietary adjustments with high vegetable, high roughage fat and salt restricted diet, stress control, alcohol cessation, and moderate exercise. 9. What are the other medical treatments given to such patients A beta-blocking agent to control angina and blood pressure, control of diabetes if indicated, control of lipids by statin agents, and antithrombotic therapay by clopidogrel or aspirin. 10. What was the complicating condition in the ICU The patient obviously has a catheter-related urinary tract infection. 11. How did you reach this diagnosis and give support of your diagnosis. The patient was nonambulatory and perhaps dehydrated when placed in the ICU immobilised. A catheter placed in the urinary bladder would drain the urine since the patient was not able to pass urine. Presence of glucose indicates diabetes and protein indicates urinary tract infection, and the bacteria is E. coli which are GNR in a clear colony. Read More