Diagnostic thinking
Sherif Gonem, Ian Pavord in Diagnosis in Acute Medicine, 2017
In general, diagnosis should be viewed as a means to an end, namely treatment, not as an end in itself. There are some cases in which a diagnosis need not be pursued any further, as it will not change the patient’s management. For instance, consider the case of an elderly nursing home resident who is found to have iron-deficiency anaemia. The causes of iron-deficiency anaemia include gastric or colonic cancer. However, if it is judged that the patient would not be fit for surgical intervention or chemotherapy even if a malignancy was to be discovered, there is no purpose in performing invasive tests such as colonoscopy or gastroscopy, as they would not change the patient’s treatment. The correct course of action would be to treat the patient symptomatically with oral iron supplements. In other cases, the diagnostic process should be pursued partially, in order to rule out serious pathology, but not necessarily completed. For instance, chest pain is a very common emergency presentation, which has a number of serious causes and many less serious causes. Doctors who are managing a patient with acute chest pain should focus initially on diagnosing or ruling out serious pathology that requires urgent treatment, such as myocardial infarction, pulmonary embolism or aortic dissection, even if these diagnoses are not the most likely ones. Once this has been done, there is little benefit in distinguishing between the remaining possible causes, such as costochondritis or viral pleurisy, as they will each be treated similarly, with simple analgesia.
Answers
Andrew Schofield, Paul Schofield in The Complete SAQ Study Guide, 2019
Microcytic anaemia is low haemoglobin and low mean cell volume. Causes include thalassaemia, sideroblastic anaemia and lead poisoning, but iron deficiency is by far the commonest cause. Iron-deficiency anaemia is most commonly caused by blood loss. Iron studies can be done to confirm diagnosis. They would show a low serum ferritin and iron with a raised total iron-binding capacity. Signs of severe anaemia are those associated with a hyperdynamic circulation. Signs more specific to iron-deficiency anaemia are mentioned above. Koilonychia is seen as spooning of the nails, angular cheilosis is splitting and cracking of the skin at the comer of the mouth, usually bilaterally, and atrophic glossitis appears as a smoothness to the tongue surface as there is loss of the papillae.
Nonhematological Manifestations of Iron Deficiency
Bo Lönnerdal in Iron Metabolism in Infants, 2020
Certainly the most important function of iron in the body is its role in oxygen transport and storage. Therefore, the consequences of iron deficiency have traditionally focused on anemia which reduces maximum oxygen consumption and maximum work performance.4–6 Other consequences of iron deficiency anemia, especially in the severe forms, have been reported. These include shortened survival of erythrocytes in infants,7 effects of anemia on serum total cholesterol and triglyceride levels,8,9 reduced leukocyte alkaline phosphatase activity, decreased nitro-blue-tetrazolium (NBT) reduction ability, impaired liver growth, and generalized depression of DNA synthesis.10 The latter may lead to increased fetal resorption, decreased fetal size, and a large decrease in total fetal weight in rats.11–13 It has also been noted that rats with iron deficiency anemia show a significantly greater incidence of tongue tumors after exposure to carcinogen.14
Iron deficiency and cyanotic breath-holding spells: The effectiveness of iron therapy
Published in Pediatric Hematology and Oncology, 2018
Sherifa A. Hamed, Eman Fathalla Gad, Tahra Kamel Sherif
Spells were defined as described in the literature by the following clinical sequence: provocation followed by crying to a point of noiselessness (as the child’s breathing stopping in expiration after a deep inspiration during crying) and accompanying change of color (cyanosis) and loss of consciousness with/without alteration in body tone or body jerks.1 We categorized spells according to their frequency as follow: mild: less than 1 per week, moderate: 1–3 spells per week and high: 4 or more spells per week. Patients were divided according to iron status into three groups: Group 1: children with cyanotic breath holding spells and iron deficiency without anemia. iron deficiency (without anemia) is defined by normal hemoglobin, reduced serum ferritin, without or with reduced serum iron; and/or transferrin saturation; and high levels of total iron binding capacity (TIBC) (as iron store is reflected by the falling of serum ferritin), Group 2: children with cyanotic breath holding spells and Iron deficiency anemia. Iron deficiency anemia is defined by iron deficiency and reduced hemoglobin. Iron deficiency anemia occurs when there is no iron for hemesynthesis21 and Group 3: children with cyanotic breath holding spells and normal iron status.
The alliance with expanding blood volume and correcting anemia is an effective therapeutic measure for the adult anemia patients of acute cerebral infarction
Published in International Journal of Neuroscience, 2018
Zunyu Ke, Yu Zhao, Chuanling Wang, Zhiyou Cai
This is a retrospective cohort analysis performed in Renmin Hospital, Hubei University of Medicine in Shiyan, Hubei Province, China, and the Fourth Hospital of Harbin Medical University in Harbin, Heilongjiang Province, China. Inclusion criteria for acute cerebral infarction were as follows: (1) age ≥ 18 years; (2) cerebral infarction was diagnosed by neurologists according to the 2013 AHA/ASA guideline. The diagnosis of iron-deficiency anemia was based on the history of anemia and the routine blood tests (male: hemoglobin < 120 g/L, and female: hemoglobin < 110 g/L). Exclusion criteria were (1) without the examination of diffusion-weighted image (DWI), unable to confirm the new characteristics of cerebral infarction; (2) other intracranial pathologies (e.g. tumor, infection) according to a cerebral CT scan or MRI; (3) not meeting the anemia diagnosis (male: hemoglobin ≥ 120 g/L and female: hemoglobin ≥ 110 g/L).
Iron supplementation given to nonanemic infants: neurocognitive functioning at 16 years
Published in Nutritional Neuroscience, 2023
Patricia L. East, Brie Reid, Estela Blanco, Raquel Burrows, Betsy Lozoff, Sheila Gahagan
Two points are important to emphasize regarding our study. The first is that iron status was not determined for all infants at enrollment into the preventive trial. Rather, enrollment was based on hemoglobin at 6 months. Because we did not have additional iron indices at 6 months, some participants could have been iron-insufficient at entry into the trial. The current results pertain only to nonanemic infants and cannot directly address the issue of iron-repletion. Secondly, this was a population at high risk for iron deficiency in infancy, and iron supplementation was highly effective in reducing that risk. Infants randomized to the iron-supplemented condition in the preventive trial were diagnosed with iron-deficiency anemia at 7-times lower rates than those randomized to the no-added iron condition (4.5% vs. 31.7%, respectively). Thus, iron supplementation for the purpose of preventing iron-deficiency anemia remains important. The question is the optimal level of supplementation. Our study used formula fortified at the level of iron recommended by the American Academy of Pediatrics at the time of the study (12.7 mg/L). Earlier results using the Chilean preventive trial sample showed that 2.3 mg/L of iron fortification in formula was sufficient to prevent IDA while resulting in better outcomes than fortification at the high level of iron supplementation [7,8]. Iron fortification in the lower range (2 mg/L) has been widely endorsed recently, with recommendations to stage formula iron content by age and breastfeeding status [25].
Related Knowledge Centers
- Anemia
- Fatigue
- Iron Deficiency
- Lightheadedness
- Shortness of Breath
- Blood
- Pallor
- Hemoglobin
- Red Blood Cell
- Shortness of Breath
- Altered Level of Consciousness