PBL 2

CASE STUDY

1. LIU XINYI BDDS20106789

2. LIM WIN NIE BDDS20106149
3. MARNI SHAFIYA BDDS20106444
4. TAN JIUN JIE BDDS20106251
5. AIMAN BDDS20106328
6. LOO VERN BDDS20106100
 Learning Outcomes

List the common Explain the Explain the histology

causes of fatigue and mechanism of fatigue of the tongue
weakness and weakness

To compare blood test To understand the

To diagnose the
result with the consequences of
symptoms shown
reference range untreated iron deficiency
for excessive blood
anemia and its
loss
treatments
Observation Comes First!

Interpreting the Triggers Given

Trigger 1

Symptom 1 Symptom 2

Anita, a 35-year-old female complains of fatigue , loss of taste sensation and weakness since
two weeks ago. She informed that she experienced excessive blood loss from the previous
menstruation which was about one month before.
 Fatigue
&
Weakness
 VS
Weakness Fatigue

- Lack of physical and - Feeling of tiredness and

exhaustion
muscle strength
- - Lack of energy or
- Extra effort is needed
strength

Symptoms
Weakness and Fatigue. MyHealth.Alberta.ca Government of Alberta Personal Health Portal. (n.d.). Retrieved 11 July 2021, from
https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=wkfat#:~:text=Weakness%20is%20a%20lack%20of%20muscle%20strength%20and%20a%20reduced,or%20extreme%20lack%20of%20energy.
 Types of Fatigue

Mental Fatigue Physical Fatigue

temporary inability to maintain temporary physical inability of
optimal cognitive performance muscles to perform optimally

Central / Neural Peripheral / Muscular

fatigue fatigue
Venning, E. (2021, June 23). What is FATIGUE? - Peak Chiropractic Cape Town. Peak Chiropractic. https://www.capetownchiro.com/sleep/what-is-fatigue/.
 Causes of physical fatigue

EXERCISE DIABETES

DEPLETION OF HYPERTHYROIDISM &

ACH AT
HYPOTHYROIDISM
MOTOR END PLATE

Anita, a 35-year-old female complains of fatigue , loss

of taste sensation and weakness since two weeks ago.
IRON DEFICIENCY ANEMIA

Boundless. (n.d.). Boundless Anatomy and Physiology. Lumen. Retrieved 11 July 2021, from https://courses.lumenlearning.com/boundless-ap/chapter/muscle-metabolism/.
Wan, J.-jing, Qin, Z., Wang, P.-yuan, Sun, Y., & Liu, X. (2017, October 6). Muscle fatigue: general understanding and treatment. Nature News. https://www.nature.com/articles/emm2017194.
 Sign and Symptoms of Fatigue
● tiredness or sleepiness
● headache
● dizziness
● muscle weakness

● reduced ability to
pay attention ● short-term memory problems
● moodiness ● low motivation

● appetite loss

● blurry vision
● Hallucinations

Fatigue. Fatigue - Better Health Channel. (n.d.). https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/fatigue.

Trigger 1

Anita, a 35-year-old female complains of fatigue , loss of taste sensation and weakness since
two weeks ago. She informed that she experienced excessive blood loss from the previous
menstruation which was about one month before.

Symptom 3
 Excessive Blood Loss
Heavy menstrual bleeding (menorrhagia) refers to bleeding lasting longer than seven days that
can be heavy at times and a common disorder in women.

Symptoms
-Heavy blood loss -Prolonged periods
-Bleeding between periods -Passing blood clots larger than a quarter
Consequences
Anemia Severed Pain

Shortness of Dysmenorrhea
Fatigue Dizziness Pale skin
breath (Menstrual Cramp)
Anemia Symptoms and Causes. (2019, August 16). Retrieved from Mayo Clinic:
https://www.mayoclinic.org/diseases-conditions/anemia/symptoms-causes/syc-20351360
 Structure of Hemoglobin

Tetrameric
protein (α2β2 )

Binding of one
oxygen to a heme
molecule
facilitates the
binding of oxygen
to another heme
Each monomer
contains heme

Britannica, T. Editors of Encyclopaedia (2020, December 15). Hemoglobin. Encyclopedia Britannica.

https://www.britannica.com/science/hemoglobin
How loss of haemoglobin will cause sign and symptoms

Someone with menorrhagia can cause medical conditions like anemia by reducing the
number of circulating red blood cells and iron in the body. With anemia, the lungs need to
pump more blood in order to bring in more oxygen, causing breathing difficulties. Next,
low levels of hemoglobin also prevent adequate oxygen from reaching the brain and the
rest part of the body. Thus, it will cause headaches, dizziness, and fatigue.

Plus, an Anemic person will have pale skin because the numbers of red blood cells
become low. There aren't enough red blood cells reaching the skin's surface when the
amount of red blood cells decreases. As the blood is subsequently diverted away from the
skin to the important organs, causing the skin becomes pale.

Are You Anemic? The Signs to Look For. (n.d.). Retrieved from Everyday Health:
https://www.everydayhealth.com/anemia/are-you-anemic-signs-look/
 ● Anatomy of tongue
● Embryology of
Tongue-development, vessel
supply and innervations
Tongue ● Specialized mucosa
● Types and location of papillae
● Clinical Symptoms on papilla
during anemia
● Taste bud structure
● Taste Perception
 Development of the Tongue
1. Begins development during the 4th week of gestation.
2. Anterior two-thirds (body) of the tongue develops from 3 swellings; 2 lingual, 1 tuberculum impar.
3. Posterior third (base) develops from a large swelling, hypobranchial eminence.
4. Hypobranchial eminence arise to the mucosa that covers the posterior third of the tongue.
5. 3rd median swelling formed by posterior third of the 4th arch marks the development of the
epiglottis.
 Dorsal
Surface

anterior 2/3

posterior 1/3

root/base

mucosa = non-keratinized
stratified squamous epithelium
Lorenzo Crumbie MBBS, B. S. (2021, June 17). Tongue. Kenhub. https://www.kenhub.com/en/library/anatomy/tongue.
 Ventral
Surface

Lorenzo Crumbie MBBS, B. S. (2021, June 17).

Tongue. Kenhub.
https://www.kenhub.com/en/library/anatomy/tongue.
 Innervations

Neurovascular
Supply of
Tongue
● Arterial Supply
○ Facial Artery- Tonsilar Branch Vascular Supply
○ Ascending Pharyngeal Artery
○ Lingual Artery- Dorsal Lingual Br, Sublingual Br, Deep Lingual Br

Anatomy of the Lingual Nerve. (2011). Dental Malpractice Central. http://www.mccullochlaw.net/nerve_injury/lingual_nerve/

Wiegand, S., Tiburtius, J., Zimmermann, A. P., Güldner, C., Eivazi, B., & Werner, J. A. (2014). Localization and treatment
of lingual venous and arteriovenous malformations. Vascular Medicine, 19(1), 49–53.
https://doi.org/10.1177/1358863x14521316
 1 Vallate 2 Foliate
Papillae Papillae
CN IX- Taste Sensation Number decreases with
age

1
2
3

4 3 Filiform 4 Fungiform
Papillae Papillae
For Tactile Sensation CN VII- Taste Sensation
Types and
Locations
of Papillae
Anatomy of the Lingual Nerve. (2011). Dental Malpractice Central. http://www.mccullochlaw.net/nerve_injury/lingual_nerve/

Introduction to the Oral Cavity and Periodontal Disease - online presentation. (n.d.). PPT Online. Retrieved July 11, 2021,
from https://en.ppt-online.org/497004
 Taste receptors
Neurological (Taste buds)

Pathway of CN VII/IX/X
Solitary Tract
Taste (Gustatory)
Nucleus

Sensation
Thalamic (Ventral
Posterior Medial )
Nucleus

● Gustatory Cortex
● Primary
Somatosensory
Cortex
● Hypothalamus &
Amygdala
● Hippocampus

Gustatory pathway. (n.d.). Brain for Ai Wiki. Retrieved July 11, 2021, from
https://brain-for-ai.fandom.com/wiki/Gustatory_pathway
Structure of taste buds
-They are sensory taste receptors that are found on
the tongue, whose function is to aid in forming taste
perception, the sensation that occurs when taste buds
carry information regarding the chemical composition
of a soluble stimulant.

- 5 known tastes that are recognized by taste buds:

Sweet, sour, salty, bitter, umami

-Taste buds send the sensory information to the

brain’s gustatory center through neurons.

The taste buds. Anatomy. (n.d.).

https://anatomy-medicine.com/nervous-system/114-the-taste-buds.html
 Mechanism of taste perception
1. Food/drink enters the mouth and lays on the pores of the tongue
surface.
2. Chemicals molecules dissolve in saliva and become tastants.
3. Tastants travel to taste receptors that are inside the taste buds and
papillae.
4. Taste receptors get stimulated by the tastants.
5. Tastants are converted into sensory information by the receptors.
6. Sensory information will proceed on the neural pathways along the
cranial nerve.
7. The sensory information reaches the thalamus and advances to the
primary gustatory cortex for analysis and interpretation.

What is the process of taste sensation and perception? (The food or drink…. Coggle.it. (2021). Retrieved 12
July 2021, from
https://coggle.it/diagram/V2ZO4Mh0sFBhLKe_/t/what-is-the-process-of-taste-sensation-and-perception.
Trigger 1 Symptom 4

Anita, a 35-year-old female complains of fatigue , loss of taste sensation and weakness since
two weeks ago. She informed that she experienced excessive blood loss from the previous
menstruation which was about one month before.

Trigger 2 Symptom 5

Upon, examination, the oral mucosa was found pale and tongue was
inflammed and appeared red in colour.

Symptom 6 Symptom 7
Lost of taste
sensation
Deficiency of folic acid or vitamin B12 in megaloblastic anemia causes
atrophy of the tongue papillae, resulting in reduced taste sensation

What causes the loss of taste

1. Scalding. 5. Nerve damage.

2. Insufficient amount of saliva. 6. Psychological diseases.

3. Deficiency of zinc, vitamin A and iron. 7. Drug effects.

4. Candida infection.
Causal factors and recommendations for resolution

Nerve degeneration --- vitamin B1, vitamin B12

Inflammation accumulation --- anti-inflammatory and anti-swelling

Nerve tumor --- surgery

Nerve disruption due to trauma or surgery --- nerve repair or graft surgery
 Suggestions

● Strengthen exercise to enhance body immunity;

● Brush the tongue as little as possible to reduce the
stimulation of tongue papillae;
● Eat less stimulating food;
● Drink more light drinks and no sweet drinks to
reduce the acidity produced by sweet substances
staying in the mouth.

Note: Pathological degeneration or loss of taste is mostly sudden, at this time people should go to the
hospital for examination in time to clarify the cause.
 Tongue
Inflammation
&
Smoothness
Everything You Need to Know About Oral Thrush. Healthline. (2021). Retrieved 12 July 2021, from
https://www.healthline.com/health/thrush#symptoms.

Everything You Need to Know About Tongue Swelling. Healthline. (2021). Retrieved 12 July 2021, from
https://www.healthline.com/symptom/tongue-swelling#causes.
 Tongue inflammation- Glossitis
Sjögren’s syndrome Allergic reactions
-leads to destruction of -toothpaste, mouthwash,
salivary glands -> dry retainer, food
mouth -> inflammation

Injury
Vitamin deficiency -trauma or burns could
cause the tongue to
-low levels of vitamin
swell
b12 or iron

Yeast infections- oral

Skin conditions thrush
-symptoms: soreness in
mouth， lost of taste
sensation
Ingestion of irritants
-substances such as alcohol, tobacco, spicy foods
 Anemia - Symptoms and causes. (2019, August 16).
Mayo Clinic.
Anemia https://www.mayoclinic.org/diseases-conditions/anemi
a/symptoms-causes/syc-20351360

Sickle Cell Vitamin Deficiency

-RBC are shaped -Lack of healthy RBC due to
differently insufficient vitamin b12,
-Difficult to pass through folate, or vitamin C.
blood vessels -Tongue might hurt.
-Tongue may appear -Tongue papilla is usually
smooth and may be sore. reduced = affects the feeling
of texture or taste
 Treatments
- Prescriptions of antibiotics, antifungals, antimicrobials
- Take vitamin b12 or iron supplements
- Quit smoking
- Decrease alcohol intake
- Observe what food you eat, toothpaste & mouthwashes you use
- Blood tests to see if iron levels are low
 Tongue Smoothness
● loss of hairlike projections
(papillae) on the surface of
the tongue
● iron - deficiency anemia,
pernicious anemia (vitamin
b12 anemia), untreated
celiac disease
● Good oral care
● Diet changes
● Supplements to treat
nutritional problems.
● Avoiding irritants (alcohol
etc.)
● Antibiotics/other
medications to treat
infection.
Trigger 3

The doctor advised complete blood count. The values were as follows:

RBC count: 3.5million cells/μL

Haemoglobin count: 8.1gm/dL

 CBC TEST RESULT

Complete
Blood
Count

● To confirm the diagnosis of a

medical condition

● A blood sample is drawn from a

vein in the arm and sent to the lab
to evaluate all the cells circulating
in blood.

● Provides information about the

red blood cells count,
haemoglobin, hematocrit, white
blood cells count and platelets
count.

RBC count: Male: 4.35-5.65 million cells/μcL

Complete Blood Count (CBC) Test. (2017, February 3). WebMD. https://www.webmd.com/a-to-z-guides/complete-blood-count
Female: 3.92-5.13 million cells/μcL
Hemoglobin count: Male: 13.2-16.6 grams/dL
Moores, D. (2018, September 17). Complete Blood Count (CBC). Healthline. https://www.healthline.com/health/cbc Female: 11.6-15 grams/dL
 Final
Diagnosis:
Iron Deficiency
Anemia
 Complications and
Treatments
Approaches needed if one is diagnosed with the iron deficiency anemia
 Watch Out!
Complications if Untreated

Cardiovascular
Immunity Increase your risk of Pregnancy
More at risk of illness developing Greater risk of
and infection – a lack of complications that complications before
iron affects the affect the heart or and after birth
immune system lungs – such as an
abnormally fast
heartbeat (tachycardia)
or heart failure

NHS website. (2021, March 9). Iron deficiency anaemia. Nhs.Uk. https://www.nhs.uk/conditions/iron-deficiency-anaemia/
 Treatments and Approaches
Iron Supplements Blood Transfusion
& Parenteral
The ingestion of iron Administration
supplement tablets
of Iron
In severe cases, iron, red blood cells and
haemoglobins need to be introduced into the
body immediately to compensate with the losses

Other Medications Dietary Modification

NSAIDs, Tranexamic Acid and progesterone Consumption of food and vegetables

tablets are prescribed to lighten the heavy rich in iron and vitamin C
menstrual flow

Iron deficiency anemia - Diagnosis and treatment. (2019, October 18). Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/diagnosis-treatment/drc-20355040
 Summary of Study Case
A 35 years old woman experienced excessive blood loss from menstruation a month ago

Complained of fatigue, loss of taste sensation and weakness for two weeks

Upon examination, her oral mucosa was pale and tongue was red and inflamed

Complete blood count test was done. Her red blood cells and haemoglobin count was
lower than normal

Patient was diagnosed with iron deficiency anemia

Patient was given treatment to increase production of red blood cells and controls
menorrhagia.

Patient was discharged

 References

Anatomy of the Lingual Nerve. (2011). Dental Malpractice Central. http://www.mccullochlaw.net/nerve_injury/lingual_nerve/

Anemia - Symptoms and causes. (2019, August 16). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/anemia/symptoms-causes/syc-20351360

Are You Anemic? The Signs to Look For. (n.d.). Retrieved from Everyday Health:

https://www.everydayhealth.com/anemia/are-you-anemic-signs-look/

Boundless. (n.d.). Boundless Anatomy and Physiology. Lumen. Retrieved 11 July 2021, from

https://courses.lumenlearning.com/boundless-ap/chapter/muscle-metabolism/.

Cherayil, B. J. (2010). Iron and Immunity: Immunological Consequences of Iron Deficiency and Overload. Archivum

Immunologiae et Therapiae Experimentalis, 58(6), 407–415. https://doi.org/10.1007/s00005-010-0095-9

Complete Blood Count (CBC) Test. (2017, February 3). WebMD. https://www.webmd.com/a-to-z-guides/complete-blood-count

Dewar, G. (2021, May 24). Boosting iron absorption: A guide to for the science-minded. PARENTING SCIENCE.

http://parentingscience.com/iron-absorption/

Everything You Need to Know About Oral Thrush. Healthline. (2021). Retrieved 12 July 2021, from

https://www.healthline.com/health/thrush#symptoms.

Everything You Need to Know About Tongue Swelling. Healthline. (2021). Retrieved 12 July 2021, from

https://www.healthline.com/symptom/tongue-swelling#causes.

Fatigue. Fatigue - Better Health Channel. (n.d.). Retrieved 11 July 2021, from

https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/fatigue.
Gustatory pathway. (n.d.). Brain for Ai Wiki. Retrieved July 11, 2021, from

https://brain-for-ai.fandom.com/wiki/Gustatory_pathway

Introduction to the Oral Cavity and Periodontal Disease - online presentation. (n.d.). PPT Online. Retrieved July 11, 2021,

from https://en.ppt-online.org/497004

Iron Deficiency (Anemia) «. (2019, December 20). Ada.

https://ada.com/conditions/iron-deficiency-anemia/

Iron deficiency anaemia symptoms and treatments. (2021). NHS Inform.

https://www.nhsinform.scot/illnesses-and-conditions/nutritional/iron-deficiency-anaemia#complications-of-iron-defici

ency-anaemia
Iron deficiency anemia - Diagnosis and treatment. (2019, October 18). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/diagnosis-treatment/drc-20355040

Iron Dextran: Uses, Interactions, Mechanism of Action | DrugBank Online. (n.d.). DrugBank. Retrieved July 11, 2021, from

https://go.drugbank.com/drugs/DB00893

Lorenzo Crumbie MBBS, B. S. (2021, June 17). Tongue. Kenhub. Retrieved 11 July 2021, from

https://www.kenhub.com/en/library/anatomy/tongue.

Lynch, S. R., & Cook, J. D. (1980). Interaction of Vitamin C and Iron. Annals of the New York Academy of Sciences, 355(1

Micronutrient), 32–44. https://doi.org/10.1111/j.1749-6632.1980.tb21325.x

Moores, D. (2018, September 17). Complete Blood Count (CBC). Healthline.

https://www.healthline.com/health/cbc
NHS website. (2021, March 9). Iron deficiency anaemia. Nhs.Uk. https://www.nhs.uk/conditions/iron-deficiency-anaemia/

Physiology of Taste. Vivo.colostate.edu. (2021). Retrieved 12 July 2021, from

http://www.vivo.colostate.edu/hbooks/pathphys/digestion/pregastric/taste.html.

The taste buds. Anatomy. (n.d.). https://anatomy-medicine.com/nervous-system/114-the-taste-buds.html.

Venning, E. (2021, June 23). What is FATIGUE? - Peak Chiropractic Cape Town. Peak Chiropractic. Retrieved 11 July 2021, from

https://www.capetownchiro.com/sleep/what-is-fatigue/

Wan, J.-jing, Qin, Z., Wang, P.-yuan, Sun, Y., & Liu, X. (2017, October 6). Muscle fatigue: general understanding and treatment.

Nature News. Retrieved 11 July 2021, from https://www.nature.com/articles/emm2017194

 Weakness and Fatigue. MyHealth.Alberta.ca Government of Alberta Personal Health Portal. (n.d.). Retrieved 11 July 2021, from

https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=wkfat#:~:text=Weakness%20is%20a%20lack%20of%20muscle%2

0strength%20and%20a%20reduced,or%20extreme%20lack%20of%20energy

What is the process of taste sensation and perception? (The food or drink…. Coggle.it. (2021). Retrieved 12 July 2021, from

https://coggle.it/diagram/V2ZO4Mh0sFBhLKe_/t/what-is-the-process-of-taste-sensation-and-perception.

Wiegand, S., Tiburtius, J., Zimmermann, A. P., Güldner, C., Eivazi, B., & Werner, J. A. (2014). Localization and treatment

of lingual venous and arteriovenous malformations. Vascular Medicine, 19(1), 49–53.

https://doi.org/10.1177/1358863x14521316

(2021). Retrieved 12 July 2021, from https://anatomy-medicine.com/nervous-system/114-the-taste-buds.html.

 Thanks !

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