Ibuprofen can be a contributing factor in developing iron-deficiency anemia. This can be attributed to blood loss. Frequent pregnancies are another factor. During pregnancies, a significant amount of iron is required to grow the fetus. Also, during childbirth, a lot of blood is lost. This needs a gap between one pregnancy to the next, preferably two years apart, to replenish the iron lost during the previous pregnancy. Another contributing factor to anemia is the use of centrally acting antihypertensive. They are associated with hemodilution and suppression of red blood cell formation.
Hormone fluctuations usually occur during menstrual bleeding and may lead to changes in bowel habits. During the days before the onset of menstrual bleeding, the levels of estrogen and progesterone are high as they prepare for pregnancy. These hormones slow the GI motility, resulting in constipation. At the onset of menstrual bleeding, the hormones reduce abruptly and sudden rise of prostaglandin levels, which results in contraction of smooth muscles, therefore, leading to diarrhea (Judkins et al., 2020). Another possible cause of diarrhea and constipation is vitamin B12 deficiency. Research shows that anemia is also associated with constipation and diarrhea.
The process of erythropoiesis requires vitamin B 12 and folic acid. They are needed during the differentiation of erythroblasts. The deficiency of vitamin B 12 and folic acid interferes with the synthesis of purines and thymidylate, which impairs the production of DNA, causing apoptosis of erythroblasts. This results in anemia due to ineffective erythropoiesis.
Pressure in the brain due to oxygen deprivation results in headaches and dizziness. Patients with iron deficiency anemia may also have easy fatigability, generalized body weakness, shortness of breath, and chest pain. Chest pain occurs mainly due to deprived oxygen in the heart muscles.
One of the signs of iron deficiency anemia is pallor. HB in the RBCs gives blood its reddish appearance. In anemia due to a deficiency of iron, the hemoglobin is low in the blood. Koilonychias is another sign which occurs due to deficient blood flow. Edema is also a sign of iron deficiency anemia. It is suggested that a reduced concentration of hemoglobin level leads to reduced inhibition of basal endothelium-derived relaxing factor, which causes vasodilation to result in fluid retention.
These findings suggest hypochromic microcytic anemia. This type of anemia is managed by administering oral or parenteral iron. Therapy includes 325 mg of ferrous sulfate three times a day. Out of this, 10 mg of iron is absorbed from the gut. Parenteral iron is used when oral route administration is associated with side effects, if anemia does not improve on oral administration or if there is continuous blood loss. The iron is prepared with sorbitol and is infused slowly over 5 minutes. For females, 35 mg/kg is the preferred dosage (Chaudhry &Kasarla, 2020). J.D. should also be instructed on consuming a diet that could boost her iron levels.
Age is a non-modifiable risk factor. With increased age, the blood vessels become tortuous, therefore increasing the risk of coronary artery disease. Ethnicity is another one. For instance, it is postulated that South Asians living in the UK are at increased risk of coronary artery disease compared to other populations in the UK. Genetics also plays a role in coronary artery disease. The modifiable risk factors include smoking, high blood pressure, a sedentary lifestyle, and obesity. Smoking leads to coronary disease by causing the deposition of plagues in the blood vessels. The plaques are composed of cholesterol, scar tissue, calcium, and other materials. This results in constriction of the blood vessels, which reduces blood flow to the muscles. Managing hypertension and diabetes can decrease the likelihood of developing a heart condition. High cholesterol is also a modifiable risk factor.
Coronary artery disease often results in ischemia in the muscles of the heart. Ischemia results in myocardial repolarization, causing ST-T changes. These changes include the depression or elevation of the ST segment, the T-wave inversion, flattening of the t wave, or the increased amplitude of the t wave. From the case scenario, several symptoms suggest an acute coronary event. These findings include chest pain, specifically radiated to the neck and the lower jaw.
One of the laboratory tests that I would choose for W.G. is cardiac Troponin 1. It is the recommended test in myocardial infarction, as it is both sensitive and specific. The diagnosis of myocardial infarction is based on the rise or fall of troponin.
High body temperature is a common finding in myocardial infarction. It occurs 4 to 8 hours of infarction onset by more than 1 degree Celsius, and the fever resolves by the fourth or the fifth day. Myocardial damage is usually associated with elevated serum levels of myocardial enzymes and c-reactive proteins, which manifests in inflammatory reactions. The necrosis of the myocardium leads to the release of inflammatory cells, which include neutrophils, monocytes, and macrophages. These cells lead to the production of several cytokines, which include IL-1, IL-6, IL-8, TNF, and interferon-gamma, which act as endogenous pyrogens. These cytokines are released into the circulation and are transported to the hypothalamic area of the brain (Jang et al., 2017). Prostaglandins produced by these cytokines often lead to the development of fever.
Oxygen is required by the cells of the heart to produce energy. In myocardial infarction, the arteries may be occluded, meaning a reduction of the flow of blood to the muscle cells. This leads to ischemia. The pain in myocardial infarction is similar to angina; however, the pain is prolonged in myocardial infarction. This pain occurs mainly during activity because physical activity increases the need for energy provided through the delivery of oxygen.
Risk Factors for the Development of Iron Deficiency Anemia
The patient J.D. presents with many factors that put her at a higher risk for developing iron deficiency anemia (IDA). These factors include; being of childbearing age, multiple pregnancies over the past 4 years, menorrhagia and the usage of aspirin a nonsteroidal antiinflammatory drug (NSAID).
Presentation of Constipation and/or Dehydration
J.D. did not present with constipation however, certain factors might place her at a risk for developing constipation. These factors include her prolonged usage of omeprazole, her dehydration status, and her being treated with a diuretic for her management of hypertension.
Importance of Vitamin B12 and Folic Acid
Vitamin B12 and folic acid each play a vital role in the production of red blood cells. Dlugasch & Story (2021) state that vitamin B12 and folic acid are both responsible for cellular DNA synthesis and maturation of erythrocytes (p. 81). If there is a deficiency in them, it could lead to premature death of cells, the inability for cells to undergo nuclear division and phagocytosis of precursor cells.
Clinical Symptoms of IDA
The clinical symptoms that support the potential for IDA include; her age, women of reproductive age have a higher risk for developing IDA, her recent pregnancies also put her at a risk for the development of IDA. Over the past 4 year, she has had 4 pregnancies, this places the demands for iron at a higher level. She also reports menorrhagia, heavy bleeding results in additional loss of iron. Lastly, her long-term use of NSAIDs (Ibuprofen), NSAIDs usage has the potential to increase GI bleeds and thus resulting in potential blood loss.
Signs of IDA
The demand for iron exceeds the supply and this eventually leads to depletion of the body’s iron stores. With fewer fully developed RBCs it is harder for the body to transport and
release oxygen without iron. Without adequate supplies of iron, the body is unable to convert the iron in hemoglobin to the ferrous state, which is how oxygen is transported in the cells. Without enough oxygen rich blood in circulation, the body starts to compensate and symptoms begin to manifest. When the body does not have enough oxygen rich blood, multiple symptoms occur. Signs I would expect to find are gradual worsening of fatigue, weakness, pale conjunctiva, pallor, shortness of breath and brittle nails.
Recommendations and Treatment
Based on J.D.’s lab results I can confirm that she does have IDA. The first thing that needs to be done is to identify the cause and/or source of her anemia (Leik, 2021, p. 323). To do so, I would conduct a thorough GI workup to rule out any potential GI conditions that could lead to blood loss. I would recommend for her to stop taking Ibuprofen until her source of anemia is identified. In the meantime, I also would recommend her to increase her consumption of iron-rich foods (red-meat, liver, fish, green leafy vegetables) and prescribe oral iron replacement along with vitamin C to aid in the absorption of iron. Iron supplements can cause constipation, so I would recommend for her to increase her fiber and water intake. Another important recommendation would be for her to avoid taking iron supplements at the same time as antacids. I would recommend repeat lab work after 2 weeks to check for treatment response.
Myocardial Infarction and Coronary Artery Disease
There are many risk factors that can lead to coronary artery disease and myocardial infarction, some risk factors are within our control and some are not. Huether & McCance (2019) states that modifiable risk factors include cigarette smoking, dyslipidemia, hypertension, diabetes and insulin resistance, obesity, sedentary lifestyle and an atherogenic diet. The non modifiable risk factors include advanced age, male gender or women after menopause, and family history (p. 1075).
On Mr. W.G’s EKG I would expect to find bundle branch blockages, with wider and deeper Q waves, along with changes in the ST segment (elevation) and T wave which are common when there is an ischemic event. The symptoms that would correlate with an acute coronary event include sudden onset of crushing sensation to the chest and pain that radiates to his neck and lower jaw. In addition, his pain did not decrease significantly after receiving oxygen, IV fluids, aspirin and morphine which are indicative of an acute coronary event.
Cardiac troponin I (cTnI) is the most specific indicator of acute myocardial infarct. It also helps to identify the size of the infarct and the likelihood of complication. I would choose this test to confirm his diagnosis of MI.
Temperature Increase After MI
The increase in Mr. W.G’s temperature is related to the inflammation that occurs from the release of plaque in his arteries. After an MI, polymorphonuclear leukocytes (PMNs) in the bone marrow mobilize into the blood, and are the first inflammatory cells to arrive at the injured myocardium, being present within hours following AMI, peaking at days 1–3, and starting to decline at day 5 (Ong et al., 2018). The onset of a fever can occur within a few hours after a MI and may last for a few days.
Sources of Pain During a MI
Mr G’s chest pain could be triggered by him playing tennis thus, physically exerting himself. With physical activity the body has a higher demand for oxygen. With a blockage in the arteries the heart is not receiving adequate oxygen rich blood and necrosis occurs.