DQ Reply 15 634

Question 1

Case Study: Anemia

Present a case study of a patient with suspected anemia. The patient may have a chief complaint of fatigue, dizziness, or failure to thrive (choose one). Include the following in the case study:

1. Identifying data

2. Chief complaint (CC)

3. History of present illness (HPI)

4. Review of systems (ROS)

5. Pertinent medications or allergies

6. Physical exam

7. Screening tools

8. Assessment, including differential diagnoses and any pitfalls of which one must be aware

Question 2

A 25-year-old female presents with a recent Hx of ammennorhea. Propose five questions you would want to ask her. Why? Identify two diagnostic tests that would be appropriate and explain why.

DQ-1

 A 22-year-old Asian male presents with a chief complaint of fatigue and weakness that has persisted over the past three weeks. He reports increasing fatigue and weakness over this time since he has been home from the hospital post-cholecystectomy. He reports his cholecystectomy was without any complications. He reports his abdominal pain is well controlled and has been diminishing, and is able to get a full eight hours of uninterrupted sleep each evening, but is requiring frequent naps and rest periods through the day after simple tasks are completed like simple chores. The visit was prompted when the patient became dizzy after standing up after a nap yesterday afternoon. 

Medical history; Denies any chronic illnesses or diseases, no history of infectious disease, no known drug allergies, no known food allergies, denies medications, no reported injuries, immunizations are up to date, and the first hospitalization three weeks ago. 

Family history; Mother- 49 healthy, Father- 50, anemia. Maternal grandmother- 74 arthritis, Maternal grandfather- 74 HTN, Paternal grandmother- 76 HTN, Paternal grandfather - 76 anemia, Younger sister- 18 - healthy. 

Social History; enrolled in college at the local university, full-time student, works part-time at local grocery store. Diets and exercises frequently at a local gym , explains that nutritional status is healthy, denies tobacco, alcohol, and illicit drug use. Denies any emotional stress or issues, and plans regular study times around work and school. Pt reports decreased socialization due to fatigue and weakness recently. 

ROS: Patient denies general changes to his body besides his surgical lap site scars on the abdomen, Denies any changes in vision- no blurry vision or distorted vision, hearing, or sense of taste or smell. Denies any difficulty eating or swallowing foods but reports a decrease in appetite, Denies any sores or lesions in his mouth. Denies any respiratory symptoms such as difficulty breathing or increased work of breathing. The patient reports heart palpitations yesterday during the dizziness episode. Denies any gastrointestinal symptoms such as heartburn, indigestion, nausea, vomiting, diarrhea, or constipation. Denies any urinary symptoms such as pain with urination, but reports urine has become dark over the past three weeks. The patient denies any joint pain, but reports weakness in general muscles increasing over the past three weeks. Patent denies any changes in the skin but reports that his mother said he was "looking a little yellow" two days ago. The patient denies any unsteady gait. The patient denies any psychiatric issues. The patient reports dizziness yesterday when trying to stand up. The patient denies bruising easily, getting sick easily, or any recent infections. 

Physical exam: This is a 22-year-old Asian male who is alert and oriented x4, cooperative, attentive, and with appropriate affect, mood, and with appropriate responses. Breathing is calm, equal, and without respiratory distress. The patient is able to walk without assistance and appears well-nourished and well-groomed. 

Vitals: Height: 5'0, 75kg, B/p 119/79, HR: 115, R: 20, T: 96.9, SpO2- 98% on room air. 

The overall appearance of the skin is pale, and the skin is cool to the touch, with no rashes, lesions, edema, or erythema noted. Hair is brittle and coarse, with no hair loss noted. The patient's face appears fatigued with darkened eyelids. Head and neck are symmetric with no rashes, lesions, edema, or erythema noted. The patient's bilateral sclera appears slightly jaundiced, pallor of the conjunctiva, and no discharge noted. Bilateral pupils are PERRLA. The nose is symmetrical with no rashes, lesions, edema, or erythema noted. Nares are free of obstructions with no rashes, lesions, edema, or erythema noted. Bilateral ears are symmetrical with no rashes, lesions, edema, or erythema noted. The external ear is free of obstructions, and internal ear is free of obstructions with no rashes, lesions, edema, or erythema noted. Bilateral tympanic membranes are pearly grey with a visible cone of lights at 5:00 and 7:00 respectively.  The mouth is symmetric with the pallor of the gingiva noted, but with no rashes, lesions, edema, or erythema, tonsils are +0, no cobblestoning noted, and vulva is intact. The neck is symmetrical with no rashes, lesions, edema, or erythema noted. No lymphatic nodes are enlarged at this time. Lung sounds are clear bilaterally and heard in all quadrants, no adventitious breath sounds noted such as wheezes, rales, or crackles, and breaths are symmetrical. Cardiac sounds reveal s1 and s2, and no s3 or s4, or murmurs noted, carotid pulses are +2, no heaves or thrills noted, no bruis noted. The abdomen is rounded, symmetrical, with no rashes, masses, lesions, edema, or erythema noted, and has active bowel sounds in all four quadrants, patient reports tenderness in the upper right quadrant, but the liver is soft and smooth, the spleen is not palpable, kidneys are non-palpable. 

Laboratory workup at this time includes: CBC, Peripheral blood smear, Iron studies- serum iron, ferritin unsaturated and total iron-binding capacity, Hemoglobin electrophoresis, Renal function panel, CMP with mag and phos, 

Differential diagnosis includes: Iron deficiency anemia, anemia secondary to recent surgery, Heavy-metal poisoning, Thalassemia minor. 

Depending on the results of the lab work will help rule in and rule out the differential diagnosis (Huang et al., 2019). Thalassemia occurs frequently in Asian and Mediterranean patients (Huang et al., 2019);(Bajwa & Basit, 2020). Some important points from the patients history is that he had a recent cholecystectomy at a young age which could have been the result of chronic hyperbilirubinemia which would explain jaundice in the sclera post-cholecystectomy (Bajwa & Basit, 2020). Also, both his father and grandfather had anemia which could indicate a genetic component that has manifested in the patient (Huang et al., 2019);(Bajwa & Basit, 2020). The results of the CBC will help indicate what type of anemia and help rule out iron deficiency anemia (Huang et al., 2019);(Bajwa & Basit, 2020). Thalassemia minor can occur later in life after major stressors such as surgery Huang et al., 2019);(Bajwa & Basit, 2020). If the patient has beta-thalassemia minor, this will be indicated on the hemoglobin electrophoresis where there will be an elevation of HbA2 and a mild decrease of HbA (Huang et al., 2019);(Bajwa & Basit, 2020). If the laboratory work rules-out iron deficiency anemia, and indicates thalassemia, a genetic test would be recommended to determine the severity (Huang et al., 2019);(Bajwa & Basit, 2020).

Treatment is dependent on severity (Huang et al., 2019);(Bajwa & Basit, 2020). Treatment usually includes blood transfusions depending on the results of hemoglobin and hematocrit (Huang et al., 2019);(Bajwa & Basit, 2020). Since this is the patient's first event, I would also recommend hospitalization for observation of blood transfusions while awaiting laboratory results along with a hematology consult (Huang et al., 2019);(Bajwa & Basit, 2020).

References:

Bajwa, H., Basit, H. (2020). Thalassemia. Treasure Island (FL): StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK545151/

Huang, Y., Liu, R., Wei, X., Liu, J., Pan, L., Yang, G., & Lai, Y. (2019). Erythropoiesis and Iron Homeostasis in Non-Transfusion-Dependent Thalassemia Patients with Extramedullary Hematopoiesis. BioMed Research International, 2019, 4504302. https://doi-org.lopes.idm.oclc.org/10.1155/2019/4504302

DQ-2

A 65 years old female patient with a history of ESRD for 10 years is coming in for chief complaint of acute fatigue and dizziness. She states that this has been going on for several weeks now. This is a new onset for her and states it has gotten worse over the weeks. She has attempted to rest and sleep more often in hope to relieve the symptoms, but all her efforts to treat herself are not successful.

The patients history has chronic disease of ESRD, HTN ,DM, no psychiatric problems, no infections, all immunizations are UpToDate, with recent hospitalizations for elevated potassium and emergency dialysis with fluid overload, no sexual transmitted infections and not in the age of bearing children nor pregnancy. patient has not family history of illness that she knows of. Patient has no allergies.

Head: intact with no hair loss, no macules , papules, vesicles, lesions, rash, irritation. Eyes: patient is blind bilaterally unable to see since 10 years ago. Ears: patient is hard of hearing bilaterall otherwise normal. Nose: patient is able to identify scent and has no drainage or problesm. Mouth: no problems with chewing food or teeth or mouth area, Throat: no abnormal heat or cold flashes and is able to swallow and eat. Resp:no sob, difficulty breathing, distress, cough. Cardiac: no chest pain , no palpitations. Abdominal: no diarrhea, no constipation, no rectal bleeding. M/S patient with loss of balance and unstable gait. Nuero: with dizziness and unsteady gait. Heme: no bruising or bleeding.

Patient is alert and orientated 4 is able to speak and articulate all history information. Ht 5’0. WT 60kg. V/S bp 130/60, HR 79, RR 20, T 98.1, O2 Sat 98 on room air.

Head: patient skin and nails are clear without papules, macules, vesicles, lesions, rash, inflammation, no clubbing on finger nails. Eyes with cornea are gray with no redness, discharge, swelling, patient reports bilateral blindness, pupils are perrla, eye exam with red reflex, disc border intact, vascular appears with sections of impingement, retina appears normal. Ears: is hard of hearing with no conduction loss of hearing, internal ear with clear tympanic membrane with no abnormalities. Mouth/Throat: mucosa membranes intact without abnormality, no teeth loss, color od mucosa is bright red. Resp: patient with no difficulty breathing all lung sounds are clear, no abnormal sounds upon palpation/ percussion. Cardiac: carotid pulses +2 bilaterally with palpable without thrills, S1,S2 sounds are noted ,without any murmurs or gallops. Cardiac palpated with no heaves or thrills or palpations. Abdominal is soft to touch no distention, hernias, bulging or pulsations noted. Bowel sounds are normal active. Renal system: patient is anuric and requires dialysis 3 times per week. No reports of pain in the urinary system.

Laboratory workup consist of CBC with peripheral smear: normocytic, normochromic red blood cells leukocytosis common,CMP, troponin, Xray, TSH , Head CT, serum iron, total iron capacity, serum ferritin. Mean corpuscular volume level. Rectal guaiac exam.

The physical finding indicate that patient is renal insufficient. This means that the renal system cannot signal erythropoietin in the stimulation of Red blood cell production. I want to know if there is enough iron and serum ferritin in order to rule out any microcytic anemia. Differential diagnosis consists of iron deficiency anemia, Dilutional Anemia, Endocrine disorder. I want to know how big the red blood cells are in order to rule out macrocytic anemia. Knowing this, and the fact that the patient has end stage renal disease may help determine the diagnosis. In this case the hemoglobin is 7.4 g/dl. Patient in this range may need erythropoietin routine injections in combination with iron supplementation is needed to stimulate red blood cells production (Srinivasan,Fredy, Chandrashekar, Saravanan,Mohanta,Manna,2016). Irons administration is always to be used in caution with patients on dialysis. Although patients are missing erythropoietin in order to stimulate red blood cells production, having lower levels of iron in the blood may exacerbate the function of producing new red blood cells. In order to prevent iron related anemia, low administrations of iron may help dialysis patients produce more red blood cells (Rostoker, 2019). Challenges and pitfalls associated with this case are that it is a difficult diagnoses to make. My biggest fear is not making a diagnosis and having the patient leave the clinic and then finding out they had an emergency related to low blood. On the other hand, making the diagnosis will have the patient take unnecessary medications that may have huge side effects specially related to hypertension. In this case I will refer the patient to a hematologist as well as prescribe iron supplementation oral route.

 

Rostoker, G. (2019). When should iron supplementation in dialysis patients be avoided, minimized or withdrawn? Seminars in Dialysis, 32(1), 22

DQ-3

The patient is a 70-year-old caucasian woman who presents with fatigue over the past 6 months. She denies cough, fever, chills, however, reports feeling short of breath for one month and has been “bruising more easily.” She denies any blood in her stool, and no recent or recurrent illnesses. Past medical history includes GERD, and complete remission from ovarian cancer 10 years ago following chemotherapy.

Review of systems (ROS)

GEN: No fevers, no night sweats. Positive for fatigue. HEENT: No lymphadenopathy or mouth sores. NEURO: negative for dizziness, seizure, or headache. CVS: no chest pain or palpitations. RESP: No cough, pos SOB. MS: negative for myalgias. ENDO: no thyroid problems, negative for weight loss/gain. GI: negative for abd pain and blood in stool. GU: negative for hematuria/flank pain/dysuria or discharge. Skin/Breast;negative for jaundice or pallor. No rashes or breast changes

 Medication- GERD-Famotidine 20mg BID    Allergies-Baclofen "Makes my legs and feet swell"

 Height, 5’2” weight, 144 lb, BMI 26.3

Visit Vitals

BP 123/77, pulse 69, temp 97.9 °F, RR 14, SpO2 97%

Physical Exam

Constitutional: General: Not in acute distress, non-toxic appearing, HENT: Head: Normocephalic and atraumatic, Eyes:General: Sclera non-icteric, pale conjunctiva. Cardiovascular: Normal rate, regular rhythm, no murmurs. Pulmonary: respiratory effort is normal, clear breath sounds in all fields. Abdominal: No distension. Bowel sounds present, no tenderness, no hepatomegaly or splenomegaly. Extremities: Upper and lower extremities: no edema, no cyanosis. Neurological: AOx4 No focal weakness, no facial droop. Her speech is normal. Psychiatric: normal mood and affect

 Screening tools

Laboratory testing showed hemoglobin 9 g/dL, hematocrit 26%, MCV 111, WBC 3.3 K/uL, platelet count 46 K/uL, and neutrophils 4000/μL. In addition to normal vitamin B12 and folic acid levels, she had normal iron stores and normal iron saturation. Her reticulocyte count was low at 2.2%. The patient’s renal and hepatic functions were also confirmed to be normal.

 This patient’s CBC demonstrated multiple cytopenias, including thrombocytopenia with no previous findings of thrombocytopenia in her history. Considering the laboratory findings, a bone marrow biopsy was ordered, which revealed 1 percent blast cells.

Assessment/Active problems

Macrocytic anemia with mild thrombocytopenia

Macrocytic anemia due to vitamin B12 deficiency was ruled out. She was also not showing any symptoms of B12 deficiency such as cognitive impairment or peripheral neuropathy/paresthesias. Alcoholism is another cause of macrocytic anemias and thrombocytopenia and should be part of the differential. Chronic consumption of more than 80 grams of alcohol per day has adverse effects on the hematologic system. Abstinence from alcohol rapidly returns elevated MCV to normal levels. A serum ETOH and GGT would help rule out alcoholism (Yang et al., 2018).

The presence of circulating blasts in this patient’s bone marrow biopsy makes myelodysplastic syndromes (MDS) very likely. MDS is a hematologic disorder that typically presents with one or more cytopenias. It can progress with complications secondary to cytopenias, with the risk of evolving into acute myeloid leukemia (AML). Patients who have undergone chemotherapy and/or radiation therapy or radioiodine therapy are at greater risk of developing MDS (Germing, Kobbe, Haas, & Gattermann, 2013).

Collaboration with a hematologist and oncologist will play an important role in monitoring this patient for signs of infections, bleeding, and severe anemia that may lead to a rapid deterioration in the patient's status. In addition to the “watch and wait" approach, treatment options include immunosuppression treatments, stem cell transplantation, and blood products (Germing et al., 2013).

 

Germing, U., Kobbe, G., Haas, R., & Gattermann, N. (2013). Myelodysplastic syndromes: diagnosis, prognosis, and treatment. Deutsches Arzteblatt international, 110(46), 783–790. https://doi.org/10.3238/arztebl.2013.0783

Yang, J., Yan, B., Yang, L., Li, H., Fan, Y., Zhu, F., Zheng, J., & Ma, X. (2018). Macrocytic anemia is associated with the severity of liver impairment in patients with hepatitis B virus-related decompensated cirrhosis: a retrospective cross-sectional study. BMC gastroenterology, 18(1), 161. https://doi.org/10.1186/s12876-018-0893-9