Academic Clinical History and Physical Note 2

History and Physical

Chief Complaint: “I have really heavy periods and feel tired all of the time, am short of breath and feel some chest pain.”

Reliability: History obtained from patient who answers questions appropriately

History of present Illness: Patient is a 29 year old female that was initially seen in the hospital after developing a PE a few days after bariatric sleeve procedure in 2014. Patient completed Xarelto therapy, however continues to have heavy periods and fatigue. Patient has been taking oral iron.

Review of Systems:

CONSTITUTIONAL: Patient is alert and oriented x3, afebrile

HEAD AND NECK: Normocephalic, No JVD

CARDIOVASCULAR: Palpitations and chest pain

RESPIRATORY: denies cough, shortness of breath, hemoptysis, or sputum

GASTROINTNTESTINAL: denies diarrhea, or blood in stools

MUSCULOSKELETAL: Denies joint/ muscle pain

NEUROLOGIC: Denies weakness, tingling, dizziness

PSYCHOLOGIC: Alert and oriented x 3

IMMUNOLOGIC/ALLERGY: denies allergies

INTEGUMENT: No visible Lesions

PULMONARY: no hx of asthma

GENTINOURINARY: Denies urinary frequency, Positive for menstrual problem and vaginal bleeding.

Past Medical History

-Blood transfusion without reported diagnosis

-Iron deficiency anemia due to chronic blood loss

-Obesity

-Depression

Past Surgical History

-Appendectomy 06/2000

-Tonsillectomy 1995

-Bariatric Sleeve 2014

Family History

-Father 65, no medical problems

-Mother 63, Thyroid cancer (age of onset 50)

-Sister 22 no medical problems

Social History

Alcohol- denies drinking

Illicit drugs- denies

Tobacco- denies

Single lives in an apartment with a roommate, feels safe

Allergies

Penicillin (hives)

Environmental

Home Medications

OTC multivitamin

Ortho Novum 777 (Birth control)

Oral Iron tablets

Wellbutrin

Physical Exam:

T: 97.3

BP: 128/70

P: 88

RR: 18

PO: 99 on RA

CONSTITUTIONAL: She is alerted to person, place, and time. Appears well nourished, positive for fatigue.

HEENT:

Head: Normocephalic and atraumatic

Eyes PERRLA

Mouth: MM moist

Nose: Normal

Throat: No redness, tonsils absent

NECK: No thyromegaly present, no tenderness, Carotid arteries +2, no bruit, trachea midline

SHOULDERS: Full range of motion

PULMONARY: Clear lung sounds

CV: Normal Sinus Rhythm, no murmurs heard

ABD: no hernias visible, no distension or rebound tenderness

SKIN: no rash noted, not diaphoretic, not erythema or pallor

NEUROLOGIC: Alert and oriented to person, place and time, positive for dizziness and weakness

PSYCHIATRIC: normal mood and affect, answers questions appropriately

MUSCULOSKELETAL: No kyphosis/lordosis/scoliosis noted

ALLERGIC/IMMUNOLOGIC: Positive for environmental allergies

Labs:

Na: 137 Alkaline Phosphatase: 83 WBC: 9.9

Cl: 103 Calcium: 9.2 Hemoglobin: 12.9

BUN: 15 Albumin: Serum 4.1 RBC: 4.39

GLUC: 85 Total Protein: 6.9 Hematocrit: 40.8

Creat: 0.88 TIBC: 363 MCV: 97

CO2: 19 Iron: 41 MCH: 30.6

K: 4.4 Iron Sat: 15 MCHC: 31.5

AST: 26 ANC: 4.3 Platelets: 343

ALT: 28 TSH: 2.0 Free T4: 1.2

Assessment

Patient is a 29 year old female with a past medical history of bariatric surgery and developing a PE a few days after. Patient also has history of heavy menstrual periods. Complications of the surgery lead to blood loss requiring a blood transfusion. Patient was placed on xarelto therapy with positive results. Menstrual periods have decreased as well. Patient still having complaints of fatigue, dizziness, shortness of breath and chest pain

Problems:

-Fatigue: Labs for thyroid and anemia

-Shortness of breath: Labs for thyroid and anemia

-Chest pain: EKG ruled out cardiac

Differential Diagnosis:

Hypothyroidism: Ruled out with assessment and labs

Anemia

Cardiac arrhythmia: Ruled out with assessment and labs

Imaging/ Test:

Ekg to rule out arrhythmias- Finding Normal sinus rhythm

Diagnosis:

Iron deficiency anemia secondary to blood loss (D50.0): With the growing prevalence of obesity in the United States, there is a rising interest in bariatric surgery. A risk factor for patients choosing to have this surgery is nutritional deficiency. There is an 18- 53% prevalence of iron deficiency in patients after having had bariatric surgery. After a gastric bypass procedure, food bypasses the small intestine which can lead to iron deficiency (Steenackers, Van der Schueren, Martens, & Lannoo, 2017). In women who already have heavy menstrual periods prior to surgery, it predisposes them to an even higher risk of iron deficiency.

Vitamin Deficiency (E56.9): Common symptoms for a patient deficient in vitamin B12 includes both weakness and fatigue. Patients who undergo bariatric surgery have a high prevalence of Vitamin B 12 deficiency. This most likely stems from the bypassing of the duodenum which is the main site of vitamin B12 absorption (Lupoli, Lembo, Saldalamacchia, Avola, Angrisani, & Capaldo, 2017).

Malabsorption Syndrome due to intolerance, not elsewhere classified (K90.49): Due to bariatric sleeve. Obese patients may choose to have a bariatric surgery as a method of treating morbid obesity. However, patients must be fully educated on dietary instructions due to an increased risk of malabsorption syndrome (Potamousi, Samaras, Gerakari, Fambri, Bouras, …& Kthanassiou, 2018).

Plan:

Injectafer 750 mg IV times 2 doses, one week apart

Cyanocobalamin injection: q weekly for one month then q monthly for maintenance

Follow up labs in one month with return visit to go over results

Geriatric Specific:

Anemia in the geriatric population is not only common but is also associated with an increased morbidity and mortality. It can hinder the functional and cognitive capacity as well leading to an increased fall risk affecting their quality of life. There are three major causes of anemia in the elderly population: nutritional deficiency, unexplained, and anemia of a chronic disease (Macedo, Dias Camara, &Antunes, 2017). Getting a thorough past medical history on all patients, especially our geriatric population, is imperative to determining the root cause of the problem. Patients who choose to have bariatric procedures may not develop anemia for years, as sometimes it takes 5-10 years to manifest (Kotkiewicz, Donaldson, Dye, Rogers, Mauger, Kong, & Eyster, 2015). Understanding their past surgical procedures and medical history can assist in determining a diagnosis to symptoms they are coming in with.

References

Chen, G. L., Kubat, E., & Eisenberg, D. (2018). Prevalence of anemia 10 years after Roux-en-Y gastric bypass in a single veterans affairs medical center. JAMA surgery, 153(1), 86-87.

Kotkiewicz, A., Donaldson, K., Dye, C., Rogers, A. M., Mauger, D., Kong, L., & Eyster, M. E. (2015). Anemia and the Need for Intravenous Iron Infusion after Roux-en-Y Gastric Bypass. Clinical medicine insights. Blood disorders, 8, 9–17. https://doi.org/10.4137/CMBD.S21825

Macedo, B. G., Dias, P. P., Camara, H. S., & Antunes, C. M. F. (2017). Functional Capacity and Anemia in the Community Elderly. Advances in Aging Research, 6(06), 93.

Lupoli, R., Lembo, E., Saldalamacchia, G., Avola, C. K., Angrisani, L., & Capaldo, B. (2017). Bariatric surgery and long-term nutritional issues. World journal of diabetes, 8(11), 464–474. https://doi.org/10.4239/wjd.v8.i11.464

Steenackers, N., Van der Schueren, B., Mertens, A., Lannoo, M., Grauwet, T., Augustijns, P., & Matthys, C. (2018). Iron deficiency after bariatric surgery: what is the real problem?. Proceedings of the Nutrition Society, 77(4), 445-455.

Potamousi, P., Samaras, C., Gerakari, S., Fambri, A., Bouras, P., Athanassiou, L., ... & Kostoglou-Athanassiou, I. (2018, May). Post bariatric surgery malabsorption and vitamin D deficiency. In 20th European Congress of Endocrinology (Vol. 56). BioScientifica.