Mr. X, age 57, presented to his physician with marked fatigue, nausea with occasional diarrhea, and a sore, swollen tongue. Lately he also has been experiencing a tingling feeling in his toes and a feeling of clumsiness. Microscopic examination of a blood sample indicated a reduced number of erythrocytes, many of which are megaloblasts, and a reduced number of leukocytes, including many large, hypersegmented cells. Hemoglobin and serum levels of vitamin B12 were below normal. Additional tests confirm pernicious anemia.

Discussion Questions

1. Relate the pathophysiology of pernicious anemia to the manifestations listed above.

2. Discuss how the gastric abnormalities contribute to vitamin B12 and iron deficiency and how vitamin B12 deficiency causes complications associated with pernicious anemia.

3. Discuss other tests that could be performed to diagnose this type of anemia.

4. Discuss the treatment available and the limitations.

Ms. L, a 19-year-old woman with no previous medical history, was involved in a serious automobile accident in which her best friend died. Examination by EMT personnel first on the scene revealed she had only minor scrapes and bruises and no sign of head trauma. While en route by ambulance to the hospital, Ms. L complained of thirst and appeared restless. Further examination indicated a rapid pulse and respirations, with her blood pressure now at 100/60 mm Hg. She appeared less responsive to the paramedics. She was slipping into circulatory shock as they checked her again for internal injuries.

Discussion Questions

1. Discuss the contributing factors to shock in this case and the pathophysiologic changes causing the changes in vital signs.

2. Discuss the signs and symptoms of shock, including the rationale for each, as seen in the early stage, and as compensation mechanisms respond.

3. Discuss emergency and follow-up treatment for shock and for complications that may arise if not treated quickly.

4. Compare the types of shock, giving a specific cause, classification, and any significant changes in onset or manifestations.

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