NURS 308 Genetic & Anemia Case Study

It’s All Greek to Me:
Physiology Edition

Part I – Something’s Not Right

Dr. James Stephens is a pediatrician serving the Tarpon
Springs, Florida, area who is seeing one of his new patients in the clinic
today. As Dr. Stephens enters the examination room, he says “kali mera” to
Stephania and Nikolaus Stamos, a greeting he uses with a number of his patients
who are Greek Americans. Mr. and Mrs. Stamos have brought in their only child,
beautiful little Nikoleta. It seems odd to Dr. Stephens that they are here because
Nikoleta’s one-year checkup is only six weeks away. Nikoleta’s parents are very

concerned and tell the doctor that the baby has been acting strangely. The
father, Nikolaus, is a personal trainer and he suspects that Nikoleta has been
anemic for some reason. Originally, Nikoleta had been on a low iron formula
because she was experiencing gastrointestinal distress. The parents changed her
formula to a high iron formula to see if it would help alleviate her symptoms,
but Nikolaus tells Dr. Stephens that it did not. His daughter continues to
suffer from general malaise and lethargy, and her skin looks a little pale
recently. Nikoleta’s parents also tell the doctor that their daughter looks
bloated all the time, and seems tired and cranky.

Dr. Stephens notices that Nikoleta’s belly appears to be
swollen. Stephania mentions that she too noticed that about a month ago, but
thought it was either gas or that the baby was gaining weight.

Nikoleta’s chart reveals that Nikoleta was in the 50th
percentile for both weight and length at the time of her birth (7lb 8oz; 20
inches). She is current with all of her vaccinations. Both parents appear
attentive and involved in her care. Mr. Stamos is average height and build
while Mrs. Stamos appears to be of small stature but within normal range. Dr.
Stephen’s assistant, Rebecca, has Nikoleta’s vital signs as follows: length 28
inches, weight 19lb 2oz, temperature 98.6. That puts Nikoleta in the 10th
percentile for both length and weight. Dr. Stephens also makes a note of the
fact that her head circumference seems relatively large.

Dr. Stephens advises the parents to switch Nikoleta back to
her original formula and orders a CBC (Complete Blood Count) panel. Then,
almost as an afterthought, he decides to order a radiograph of the skull.
“Something just doesn’t look right about her head,” he says to himself.

Questions

1. What does
it mean that Nikoleta is in the 10th percentile for both length and weight? Is
that a desirable statistic if she was in the 50th percentile at birth?

2. What are
the symptoms of anemia?

3. Why did
the parents change Nikoleta’s formula to a high iron baby formula?

4. What are
some possible reasons why Nikoleta’s abdomen is distended?

Part II – The Test Results

Dr. Stephens receives the lab reports and decides to refer
Nikoleta to a hematologist. The results are as follows:

	Value	Normal
Hb (hemoglobin)	5g/dL	Male: 13.5–16.5 g/dL
		Female: 12.0–15.0 g/dL
RBC (red blood cell count)	4.6 ×106 cells/ml	Male: 4.5–5.5 × 106 cells/ml
		Female: 4.0–4.9 × 106 cells/ml
MCV (mean corpuscular volume)	65	80–100
WBC (white blood cell count)	15,000 cells/ml	4500–10,000 cells/ml
Platelet count	250,000	100,000–450,000

Mr. and Mrs. Stamos bring little Nikoleta into the
hematologist’s office and Nikoleta has her blood drawn. After a few minutes,
the hematologist returns to speak with the parents. Even with just a few
moments looking at the sample, he knows that there is something wrong. The
hematologist reports that he observed severe hypochromia and microcytosis
(lightly colored and small cells), fragmented and nucleated RBCs.

The blood sample taken in the office appears as follows:

.jpg”>

Figure 1A. Nikoleta’s red blood cells Figure 1B. Normal red blood cells

The hematologist meets with the Stamos family in the exam
room. “Mr. and Mrs. Stamos, there are some things that do not look normal in
Nikoleta’s blood. I am not sure of the cause, but I do know that Nikoleta’s red
blood cells aren’t shaped correctly and they are not the right color. The red
blood cells should be very red under the microscope and her red blood cells are
light pink.”

Mrs. Stamos asks, “Does it matter if her red blood cells
aren’t red?”

The hematologist replies, “Yes, it does matter. Healthy red
blood cells are very red and carry oxygen. Nikoleta’s red blood cells aren’t
able to carry much oxygen to her tissues. I have an additional concern as well.
Sometimes disorders like anemia can have a genetic basis. I would like to have
both of you to give a sample of blood for a complete blood count.”

The findings from both parents are mild hypochromia and
macrocytic (lightly colored and large cells) anemia. The hematologist gives a
diagnosis of erythroblastic anemia for both Mr. and Mrs. Stamos.

Questions

5. Are the lab results of the CBC normal? Which values are
normal and which are not?

6. Why are
there different normal values for hemoglobin levels and RBC count in males and
females?

7. Do red
blood cells normally have nuclei?

8. Why was
an analysis of Mr. and Mrs. Stamos’ blood ordered?

9. Would a
picture of Mr. Stamos’ red blood cells look like Nikoleta’s red blood cells?

10. What is
erythroblastic anemia?

Dr. Stephens receives a full report from the hematologist
and digital images of Nikoleta’s skull.

Figure 2A. Nikoleta’s skull radiograph.

.jpg”>Figure 2B. Normal skull radiograph.

Question

11. Does the radiograph of Nikelta’s skull appear normal?
How are the two radiographs different?

Part III – The Family Returns

Dr. Stephens calls Mr. and Mrs. Stamos and asks that they
come in for a follow-up visit. This time the parents meet with Dr. Stephens in
his office, not in the exam room. After they are seated, Dr. Stephens informs
them that Nikoleta’s condition is very serious.

“I am sorry to give you bad news. Nikoleta does have anemia
but, unfortunately, giving her a high iron formula was exactly the opposite of
what should be done. Nikoleta’s disorder has a genetic basis.”

“But neither one of us has any of the problems Nikoleta has.
We aren’t tired all the time. We work out every day,” replies Mr. Stamos.

“That’s a very good thing, and it has probably helped to
keep you and your wife healthy. You both have a much milder form of anemia.
Unfortunately, Nikoleta’s condition is more severe.”

Questions

12. What is
the most likely diagnosis for Nikoleta?

13. What are
the general features of this disease?

Part IV – The Doctor Continues

Dr. Stephens continues, “Nikoleta has what is known as
beta-thalassemia, which is also called Cooley’s anemia. Do you remember when I
spoke with you about hemoglobin and how it functions to carry oxygen? Well,
there are two types of hemoglobin proteins involved in the process of carrying
oxygen, alpha and beta. You need both of them in order to have properly working
hemoglobin. Nikoleta’s beta proteins don’t function correctly. I have spoken to
Dr. Jeff Williams, a hematologist who specializes in childhood disorders of the
blood. Nikoleta’s condition is very grave and it has a high mortality rate. Her
life span may be significantly shortened. Dr. Williams is the best specialist
in this area and I believe he will give her the best care possible. He will
keep me informed of Nikoleta’s progress. Meanwhile, Nikoleta will still need to
see me for her regular checkups. Also, I don’t know what you are considering
for the future of your family, but because of these findings, I suggest that
you see a genetic counselor before deciding to have another baby. A genetic
counselor will give you all the information about how beta-thalassemia is
transmitted from parent to child so that you can make an informed decision
about having more children naturally.”

Questions

14. What is
the structure of hemoglobin and how is oxygen bound to it?

15. What are
some possible treatments that Dr. Williams will suggest?

16. If you
were the genetic counselor, what would you suggest to Mr. and Mrs. Stamos concerning
having more children? Why?

NURS 308 Genetic & Anemia Case Study References

Infant formulas.

http://www.medicinenet.com/infant_formulas.

Cooley’s Anemia Facts and Background.

http://www.cooleysanemia.org

Children’s Hospital Oakland, Northern California
Comprehensive Thalassemia Center website.

http://www.thalassemia.com.

Cooley’s Anemia Foundation, Inc. website.

http://www.thalassemia.org/gohome.html.

Joint Center for Sickle Cell and Thalassemic Disorders
website.

http://cancer.mgh.harvard.edu/medOnc/sickle.htm

Website describing main features and treatments of
thalassemia.

http://www.wrongdiagnosis.com/b/beta_thalassemia

3D models of hemoglobin showing binding of heme and iron.
http://www.umass.edu/molvis/tutorials/hemoglobin/heme.htm

Marengo-Rowe, A J.2006. Structure-function relations of
human hemoglobins. Proc (Bayl Univ Med Cent) 19(3): 239–245.

Image Credits

Fig. 1A—Image reprinted with permission from Medscape.com,
2011. Available at: http://emedicine.medscape.com/ article/958850-overview.

Fig. 1B—Digitally altered version of a public domain image
from CDC, ID#12104, http://phil.cdc.gov/phil/details.asp.

Fig. 2A—Radiograph from the “Film Teaching Collection”
assembled by David J. Sartoris, used with permission of collection custodian,
Tudor Hughes,
http://bonepit.com/Cases/David%20Sartoris/David%20Sartoris%20Thalassemia.htm.

Fig. 2B—Image courtesy of Dr. Frank Gaillard,
Radiopaedia.org (http://radiopaedia.org/), (original file at http://
radiopaedia.org/cases/normal-skull-x-ray), Creative Commons BY-SA-NC
(http://radiopaedia.org/licence).

Case copyright held by the National Center for Case Study
Teaching in Science, University at Buffalo, State University of New York.
Originally published February 21, 2012. Please see our usage guidelines, which
outline our policy concerning permissible reproduction of this work.

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NURS 308 Genetic & Anemia Case Study Grading Rubric

Performance Category	100% or highest level of performance 100% 16 points	Very good or high level of performance 88% 14 points	Acceptable level of performance 81% 13 points	Inadequate demonstration of expectations 68% 11 points	Deficient level of performance 56% 9 points	Failing level of performance 55% or less 0 points
Total Points Possible= 50	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic topics.	Presentation of information was exceptional and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was good, but was superficial in places and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was minimally demonstrated in all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in one of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in two of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in three or more of the following elements Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Application of Course Knowledge Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations	Presentation of information was exceptional and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was good, but was superficial in places and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was minimally demonstrated in the all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in one of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from and scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in two of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in three of the following elements Applies principles, knowledge and information and scholarly resources to the required topic. Applies facts, principles or concepts learned scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.
	10 Points	9 Points			6 Points	0 Points
Interactive Dialogue Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic.	Demonstrated all of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 3 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.			Demonstrated 2 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 1 or less of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.
	8 Points	7 Points	6 Points	5 Points	4 Points	0 Points
Grammar, Syntax, APA Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error.	The following was present: 0-3 errors in APA format AND Responses have 0-3 grammatical, spelling or punctuation errors AND Writing style is generally clear, focused on topic,and facilitates communication.	The following was present: 4-6 errors in APA format. AND/OR Responses have 4-5 grammatical, spelling or punctuation errors AND/OR Writing style is somewhat focused on topic.	The following was present: 7-9 errors in APA format. AND/OR Responses have 6-7 grammatical, spelling or punctuation errors AND/OR Writing style is slightly focused on topic making discussion difficult to understand.	The following was present: 10- 12 errors in APA format AND/OR Responses have 8-9 grammatical, spelling and punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand.	The following was present: 13 – 15 errors in APA format AND/OR Responses have 8-10 grammatical, spelling or punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand. AND/OR The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.	The following was present: 16 to greater errors in APA format. AND/OR Responses have more than 10 grammatical, spelling or punctuation errors. AND/OR Writing style does not facilitate communication
	0 Points Deducted					5 Points Lost
Participation Requirements	Demonstrated the following: Initial, peer, and faculty postings were made on 3 separate days					Failed to demonstrate the following: Initial, peer, and faculty postings were made on 3 separate days
	0 Points Lost					5 Points Lost
Due Date Requirements	Demonstrated all of the following: The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.					Demonstrates one or less of the following. The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.