History

Fact Explanation
Weakness and lethargy Due to low Hb levels lead to less oxygen supply to tissues cause weakness (1)
Palpitation Increased tissue demand increased pumping action of the heart cause palpitation (1)
Shortness of breath on exertion Increased oxygen demand leads to increase respiration and its effort (1)
Angina Hypoxia of the cardiac cells due to hyperactive of the heart causing chest pain (1)
History of alcoholism Alcohol reduce absorption of folic acid and increases excretes via urine (2)
Risk people Pregnant mothers, women of child bearing age, infants, old adults (1.3)
Children- showing irritability, chronic diarrhea and failure to thrive Due to folate deficiency.(4)
References
  1. HOFFBRAND, A.V,Megaloblastic anaemias and other macrocytic anaemias.HOFFBRAND, A.V, J.E.PETTIT, P.A.H.MOSS. Essential Haematology. 4th ed. Italy: Blackwell, 2006,pp.48
  2. Ed. KLATT,Edward C. Raminder KUMAR, Richard N. MITCHELL. Hematopoietic & Lymphoid Systems. KUMAR, vinay, Abul K. ABBAS, Jon C. ASTER. Robbins Basic Pathology. 9th ed. India: Elsevier, a division of Reed Elsevier India pvt, 2013, pp.423
  3. DUQUE X, FLORES-HERANDEZ S, FLORES-HUERTA S, et al. Prevalence of anemia and deficiency of iron, folic acid, and zinc in children younger than 2 years of age who use the health services provided by the Mexican Social Security Institute [online].BMC Public Health.2007;7(1):345.[viewed 05 May 2014].Available from: doi:10.1186/1471-2458-7-345
  4. LAUER B, SPECTOR N. Vitamins. Pediatr[online]. Rev. 2012;33(8):339-5.[viewed 07 May 2014].Available from:http://www.ncbi.nlm.nih.gov/pubmed/22855926

Examination

Fact Explanation
Pallor Reduced Hb levels as a result of bone marrow hypo proliferation leading to reduced RBC production (1)
Atrophic painful glossitis Reduced renewal of mucous membranes of the tongue (1)
Angular stomatitis Reduced renewal of mucous membranes of the corners of the mouth (1)
Bleeding disorders like petechiae reduction of production of platelets in bone marrow (1)
References
  1. HOFFBRAND, A.V,Megaloblastic anaemias and other macrocytic anaemias.HOFFBRAND, A.V, J.E.PETTIT, P.A.H.MOSS. Essential Haematology. 4th ed. Italy: Blackwell, 2006,pp.48,49

Differential Diagnoses

Fact Explanation
Vitamin B12 deficiency anaemia Vitamin B12 deficiency anaemia can be due to Pernicious Anaemia,which is an auto immune disease leading to atrophy the gastric mucosa causing reduction of Intrinsic Factor which helps to absorption of Vitamin B12. Important differential to exclude if patient is not having any neurological disorders (1.2)
Fe deficiency anaemia Important differential to exclude if patient is not having painless glossitis, dysphagia, koilonychia & pica and also the dietary history must be considered (1.2)
References
  1. HOFFBRAND, A.V,Megaloblastic anaemias and other macrocytic anaemias.HOFFBRAND, A.V, J.E.PETTIT, P.A.H.MOSS. Essential Haematology. 4th ed. Italy: Blackwell, 2006,pp. 31,43,47
  2. Ed. KLATT,Edward C. Raminder KUMAR, Richard N. MITCHELL. Hematopoietic & Lymphoid Systems. KUMAR, vinay, Abul K. ABBAS, Jon C. ASTER. Robbins Basic Pathology. 9th ed. India: Elsevier, a division of Reed Elsevier India pvt, 2013, pp.420,422,432

Investigations - for Diagnosis

Fact Explanation
Full Blood Count To detect the Haemoglobin Levels, macrocytes using red cell indices, the number of reticulocytes [ in severe defeciencies the number of all blood cells get reduced and this is called as pancytopenia] (3.5)
Blood picture To detect macrocytes, hyper segmented neutrophils in the blood (1.2)
Serum folate levels To detect folate levels within reference range (normal 2.5-13.5 ng/ml). (3.5)
Bone marrow biopsy To detect megaloblasts (2)
Serum homocysteine level To detect homocysteine level within reference range (4)
References
  1. HOFFBRAND, A.V,Megaloblastic anaemias and other macrocytic anaemias.HOFFBRAND, A.V, J.E.PETTIT, P.A.H.MOSS. Essential Haematology. 4th ed. Italy: Blackwell, 2006,pp. 51
  2. Ed. KLATT,Edward C. Raminder KUMAR, Richard N. MITCHELL. Hematopoietic & Lymphoid Systems. KUMAR, vinay, Abul K. ABBAS, Jon C. ASTER. Robbins Basic Pathology. 9th ed. India: Elsevier, a division of Reed Elsevier India pvt, 2013, pp.422
  3. MURPHY, M.F., J.S. WAINSCOAT, K.J. PASI. Haematological disease. ed. KUMAR, Parveen and Michal CLARK. KUMAR & CLARK Clinical Medicine. 8th ed. Spain: Elsevier Ltd,2012, pp. 382
  4. POMERAI KW, MUDYIRADIMA RF, TSHIMANGA M, MUCHEKEZA M. Evaluation of the Acute Flacid Paralysis (AFP) Surveillance System in Bikita District Masvingo Province 2010.[online]. BMC Res Notes. 2014;7(1):252.[viewed 06 May 2014].Available from:www.aafp.org/afp/2010/0901/p480.html
  5. KEARNS RD, CAIRNS BA, CAIRNS CB. Surge Capacity and Capability. A Review of the History and Where the Science is Today Regarding Surge Capacity during a Mass Casualty Disaster 2010.[online] Front Public Health. 2014;2:29..[viewed 06 May 2014].Available from:doi:+10.1136/bcr.03.2010.2851.

Investigations - Followup

Fact Explanation
Prophylactic Folic Acid for all women planning a pregnancy. To reduction the risk of getting neural tube defect in babies. (1)
References
  1. MURPHY, M.F., J.S. WAINSCOAT, K.J. PASI. Haematological disease. ed. KUMAR, Parveen and Michal CLARK. KUMAR & CLARK Clinical Medicine. 8th ed. Spain: Elsevier Ltd,2012, pp. 384

Management - General Measures

Fact Explanation
Dietary modifications requirement of folic acid. Add Folate rich vegetables/fruits in to the meals like Baby soyabeans, okra, spinach, asparagus, lettuce, avarcado, papaya, orange juice,mango to correct daily requirement of folic acid. (1)
References
  1. MURPHY, M.F., J.S. WAINSCOAT, K.J. PASI. Haematological disease. ed. KUMAR, Parveen and Michal CLARK. KUMAR & CLARK Clinical Medicine. 8th ed. Spain: Elsevier Ltd,2012, pp.384

Management - Specific Treatments

Fact Explanation
Give oral folic acid for 4 months (0.4-1 mg/day) To correct serum folate levels (1)
Treat the underlying specific cause leading to folate deficiency anaemia. Coeliac disease which is a condition small intestine fails to digest and absorb food. (1)
References
  1. MURPHY, M.F., J.S. WAINSCOAT, K.J. PASI. Haematological disease. ed. KUMAR, Parveen and Michal CLARK. KUMAR & CLARK Clinical Medicine. 8th ed. Spain: Elsevier Ltd,2012, pp. 384