Blood Integrated Case Studies

PHAR1802: BLOOD Integrated Case Studies (PHAR1802-2023-601-W1/XX) Learning outcomes: • To demonstrate understanding of the causes, symptoms, and risk factors for common conditions affecting the blood. • To apply a basic level of interpretation to blood test results in the context of diagnosing these types of conditions. • To demonstrate how different elements of the biopsychosocial model can be applied to the • case of treating vitamin B12 deficiency, and the factors that may influence a patient’s choice of treatment To understand the importance of correct diagnosis of a megaloblastic anaemia. Essential pre-work: Before the integrated case studies session, you should view the podcasts on the various forms of anaemia and make your own notes. Work through the case studies below and answer the questions ahead of the class where there will be the opportunity to discuss these conditions and their treatment, and to demonstrate your understanding. Blood Case Study 1 Scenario Mrs Patel is 84 years old. She visits her GP because recently she has been feeling very tired. She has also been finding herself short of breath. -general Symptoms general symptoms The GP takes a sample of blood to perform a full blood count. The results are as follows: Test Red blood cell count Haemoglobin Result Reference values 4.5 x 109/L 4.5 – 6.5 x 109/L 90 g/L 115 – 165 g/L (Females) 130 - 180 g/L (Males) in levels T indicate - andemia normocytic ? Mean Cell Volume White blood cell count Platelets Haematocrit Mean cell haemoglobin Mean cell haemoglobin concentration 70 fL 8 x109/L 236 x 109/L 0.38 L/L 24 295 g/L 80 – 99 fL 4 – 11 x 109/L 140 – 400 x 109/L 0.38-0.54 L/L 27 – 32 pg 316-365 g/L Neutrophils Lymphocytes Monocytes Eosinophils Basophils 5 x 109/L 1.8 – 8.0 x 109/L 4 x 109/L 1.5 – 4.5 x 109/L 0.5 x 109/L 0.2 – 0.8 x 109/L 0.1 x 109/L 0.04 – 0.4 x 109/L 0.05 x 109/L 0.02 – 0.1 x 109/L The GP orders additional tests to be carried out to clarify the diagnosis. The results are as follows: Test Serum ferritin Result 8 µg/L Serum iron 10 µmol/L Total iron binding capacity 100 µmol/L Vitamin B12 450 ng/L Serum folate 10.0 µg/L Reference values 10 – 420 µg/L 14 – 28 µmol/L 54 – 75 µmol/L 220 – 700 ng/L 2.6 – 17.3 µg/L Questions 1a) Mrs Patel receives a diagnosis. Identifying the abnormalities in Mrs Patel’s blood test results, what do you think the diagnosis is? 1b) How does the identified abnormality contribute to Mrs Patel’s symptoms? Mrs Patel’s GP prescribes ferrous sulphate (200 mg, 3 times a day). 2a. Using the information given in the BNF, calculate how much elemental iron Mrs Patel would receive taking this dose of ferrous sulphate? 2b. Is the prescribed dose most appropriate for the treatment of this type of anaemia? When she visits the pharmacy with her prescription Mrs Patel mentions that she would prefer a liquid formulation rather than having to take tablets. The pharmacist decides to give Mrs Patel ferrous fumerate in liquid form 2c. In the BNF it states that ferrous fumerate liquid contains 140 mg/5 ml ferrous fumerate. The molecular weight of ferrous fumerate is 170g/mol, and the atomic mass of iron is 56 g/mol. Using this information and your answer to Q2a, calculate the volume of liquid you need to supply to Mrs Patel to last for a 2-week period. 3. Which counselling points do you think are most important for Mrs Patel and why? Post-workshop tasks As a pharmacist you often need to establish why iron supplements may not have worked in resolving anaemia. Consider three possible reasons why this could happen. Create a table of all available iron salt preparations, which compares their relative elemental iron content to use for your own reference purposes. Blood Case Study 2 Scenario A 28-year-old female patient, Miss MA, presents to her GP complaining of tiredness, feeling short of breath on mild exertion, and a sore red tongue that has persisted over the past 4 weeks. The GP decides to run some blood tests, which are reported 1 week later as follows: Test Test Result Reference Range Haemoglobin (Hb) 102 g/L 115 – 165 g/L Mean Cell Volume (MCV) 105 fL 80 – 99 fL White Blood Cells (WBC) 4.6 (x109/L) 4 – 11 (x109/L) Platelets 348 (x109/L) 140 – 400 (x109/L) Based on these results, the GP decides to carry out a further test on the blood sample for levels of folate and vitamin B12. On further questioning, Miss MA also reveals that she does not smoke, drinks alcohol occasionally, and has become a strict vegan over the past 2 years following attempts to improve her diet. Questions 1. Explain the likely diagnosis given to Miss MA from the blood test results and her presenting symptoms and consider the most likely risk factor she has for developing this condition. Miss MA is found to have a low folate level, but the GP is still awaiting a result for the vitamin B12 level. Folate and vitamin B12 both play an important role in the synthesis of DNA in maturing red blood cells, acting as co-enzymes in several biochemical reactions. 2. Explain why treating Miss MA with folic acid alone would not be a safe approach to resolve her presenting symptoms and blood test abnormalities. Miss MA is also found to be deficient in vitamin B12 and is asked to return to the surgery to receive an intramuscular injection of hydroxocobalamin. She is told the cause of her deficiency is of dietary origin, and not due to poor absorption (e.g., pernicious anaemia). You (the community pharmacist) are visited by Miss MA, who tells you that she does not want to receive painful injections. Instead, she is seeking your advice on the availability of tablets that she could purchase. You are aware that cyanocobalamin tablets are licensed in the UK for treating vitamin B12 deficiency, but that they contain an animal product in their formulation. 3a) Considering the biopsychosocial model, what biological, psychological and social factors could be influencing Miss MA’s health-related behaviour (i.e., preferring to take tablets instead of injections)? 3b) How might you utilise your understanding of these influences when explaining the different options available to Miss MA and in the health advice you provide? Post-workshop tasks 1. A key role played by pharmacists is using our knowledge of non-pharmacological interventions to give useful advice on lifestyle changes – your understanding of food groups that contain good sources of folate and vitamin B12 would certainly help patients at risk who wish to find out more on preventing deficiency. Make a list of common food groups that contain good sources of folate and vitamin B12.