Case Study Assignment 2 Melinda VanKooten Simmons University NURP 532 - FNP II Primary Care Nursing April 11, 2021

Case Study Assignment 2 Melinda VanKooten Simmons University NURP 532 - FNP II Primary Care Nursing April 11, 2021 Case Study Assignment 2 HEMATOLOGY CASE A 58-year-old woman who is a long-term vegetarian and has a PMH of osteopenia, hypertension and well controlled type 2 diabetes presents to primary care with complaints of progressive fatigue and weakness for the past 6 months. She is short of breath after walking several blocks. She has noted intermittent numbness and tingling of her lower extremities and a loss of balance while walking. She denies other neurologic or cardiac symptoms and has no history of black or bloody stools or other blood loss. On physical examination, her vital signs are within normal limits. HEENT exam is notable for slightly pale conjunctiva. Neurologic examination reveals normal sensation to position and vibration in the lower extremities, 5/5 strength, and normal reflexes. She takes calcium with vitamin D, lisinopril 10mg daily, and metformin 500 mg twice daily. Laboratory testing shows a low hemoglobin (9.8 g/dL) and hematocrit level (31%), elevated MCV, elevated RDW, and low reticulocyte count. Her white blood cell and platelet count are normal. Her thyroid hormone (TSH) and comprehensive metabolic panel (CMP) are normal. Her hemoglobin A1C is 6.5 and her ECG is normal. CASE ANALYSIS What type of anemia does this patient have (macrocytic, microcytic, or normocytic) and explain why? Based on the laboratory finding of an elevated mean corpuscular volume (MCV), the patient has macrocytic anemia (Nagao & Hirokawa, 2017). When the cells grow too large, there are fewer of them than there needs to be, and they carry less hemoglobin. This means the blood is not as oxygen rich as it should be. Low blood oxygen can cause a range of symptoms and health problems. For vegetarians who give up all meat and animal products including dairy and eggs, macrocytic anemia can be caused by a vitamin B12 deficiency. Vitamin B12 is abundant in animal products, so vegans and vegetarians are more at risk of a vitamin B12 deficiency. Based on the patient’s symptoms, exam, and lab findings, what is the most likely diagnosis and provide your rationale? List 2 other differential diagnosis along with symptoms and clinical findings associated with each. Macrocytic anemia is almost always due to a deficiency of folate or vitamin B12 (Buttaro et al., 2021). The most common cause of macrocytic anemia is megaloblastic anemia, which is the result of impaired DNA synthesis. In vitamin B12 and folic acid deficiency, the defect in DNA synthesis affects rapidly dividing cells such as red blood cells. Although DNA synthesis is impaired, RNA synthesis is unaffected, leading to a buildup of cytoplasmic components in a slowly dividing cell. This results in a larger-than-normal cell. Symptoms of all types of anemias include fatigue, shortness of breath, dizziness, headache, coldness in the hands and feet, pale skin, and chest pain (Sommers, 2015). Vitamin B12 deficiency may lead to nerve damage and brain dysfunction, which causes tingling and numbness in the hands and feet, muscle weakness, and loss of reflexes. The patient may also feel unsteady and have trouble walking. Pernicious anemia is a progressive type of macrocytic anemia caused by a vitamin B12 deficiency related to malabsorption of B12 due to lack of intrinsic factor (Sommers, 2015). Intrinsic factor is a protein found in the stomach that is necessary for binding with dietary vitamin B12 so it can be absorbed. The deficiency of vitamin B12 inhibits the growth of red blood cells and leads to the production of insufficient and deformed red blood cells with poor oxygen-carrying capacity. Pernicious anemia also impairs myelin formation and thus alters the structure and disrupts the function of the peripheral nerves, spinal cord, and brain