Patient’s Information
Age: 43 years Sex: Female.
Subjective
Chief Complaint
“Coming to learn the information about test results.”
History of the Present Illness
The patient has come to learn about her test results. The patient states that her symptoms of a seasonal allergy have improved, as well as her symptoms related to gastritis. Still, the patient’s palms are yellowish. She is negative for rectal bleeding and hematuria.
Medications
- Omeprazole – 20 mg/day (gastritis);
- Loratadine – 10 mg/day (allergy).
Past Medical History
Allergies
Seasonal allergy. No drug or food allergies.
Medication Intolerances
No medication intolerances.
Chronic Illnesses/Major traumas
Seasonal allergy, gastritis. No major traumas were determined.
Hospitalizations/Surgeries
No hospitalizations or surgeries in the past.
Family History
The patient’s father, mother, grandparents, and siblings are negative for diabetes, heart disease, HTN, asthma, lung disease, peptic ulcer disease, cancer, tuberculosis, thyroid problems, kidney disease, and psychiatric illnesses.
Social History
The patient is from Mexico. She is married. She works full time. The patient has no history of abusing substances or alcohol. She has no history of smoking and consuming marijuana. The patient follows a low-fat diet because of gastritis.
Review of Systems (Only Symptoms)
General
The patient reports no weight changes, fatigue, fever, chills, or night sweats. A normal level of energy is observed.
Cardiovascular
The patient denies chest pain, palpitations, discomfort, orthopnea, and edema.
Skin
The patient is positive for changing the color of the skin on palms (yellowish). The patient denies delayed healing, bruising, rashes, or bleeding. No changes in lesions or moles.
Respiratory
She denies cough, shortness of breath, wheezing, hemoptysis, pneumonia, dyspnea, or tuberculosis.
Eyes
She denies using corrective lenses and having visual changes.
Gastrointestinal
The patient is positive for symptoms of gastritis. She denies abdominal pain, nausea, vomiting, diarrhea, constipation, rectal bleeding. She also denies hepatitis, hemorrhoids, eating disorders, and ulcers. The patient denies taking carrots excessively.
Ears
The patient denies ear pain, hearing loss, or ringing in ears.
Genitourinary/Gynecological
The patient denies changes in urgency and frequency of urinating, no hematuria. She denies vaginal discharge, no menstrual complaints.
Nose/Mouth/Throat
The patient is positive for allergic rhinitis. She denies dysphagia, nose bleeding, dental diseases, throat pain, or hoarseness.
Musculoskeletal
The patient denies back pain, joint swelling, stiffness, and osteoporosis.
Breast
The patient denies feeling pain, observing lumps, or bumps.
Neurological
She denies syncope, transient paralysis, seizures, paresthesias, weakness, and blackout spells.
Heme/Lymph/Endo
HIV status is negative. The patient denies blood transfusion, night sweats, swollen glands, bruising, increased hunger or thirst, cold or heat intolerance.
Psychiatric
She denies anxiety, depression, sleeping disorders, or suicidal ideations and attempts.
Objective
Weight: 150 pounds. BMI 20.3. Temp 98.0 F (oral). BP 120/60 mmHg. Height 6′ 0″. Pulse 110 bpm (regular). Resp 17 bpm.
General Appearance
The healthy appearing adult female, no acute distress. She is rather alert and oriented and answers questions appropriately.
Skin
The skin on palms is yellowish; it is warm, dry, and clean. No rashes or lesions are observed.
HEENT
Head is normocephalic, atraumatic, without lesions, and hair is distributed evenly.
Eyes: Pupils equally react to light and accommodation. Extra-ocular muscles are intact. No conjunctival or scleral injection is observed.
Ears: Canals are patent, bilateral tympanic membranes are pearly grey, a positive light reflex is observed, and landmarks are visualized.
Nose: Nasal mucosa is of normal color; allergic rhinitis.
The neck is supple; a full range of motion is observed. No cervical lymphadenopathy and no occipital nodes are observed—no thyromegaly or nodules. Oral mucosa is pale. The pharynx is nonerythematous; no exudate.
Teeth are in a good state.
Cardiovascular
S1, S2 with a regular rate and rhythm. No extra sounds, rubs, murmurs are observed. Capillary refill 2 seconds. No edema.
Respiratory
The chest wall is symmetric; the lungs are clear to auscultation. Respirations are regular and easy.
Gastrointestinal
The patient’s abdomen is soft, non-tender; no masses are observed. Bowel sounds are present in all four quadrants. No hepatosplenomegaly.
Breast
No masses or tenderness is observed, with no discharge. No changes in the skin; no dimpling, wrinkling, or discoloration.
Genitourinary
The patient’s bladder is non-distended; no CVA tenderness. External genitalia: skin color is consistent. No vulvar lesions noted. Vaginal walls are pale. No CMT. The uterus is normally located; no fullness, masses, or tenderness.
Rectal function: no evidence of fissures, hemorrhoids, bleeding, and masses.
Musculoskeletal
A full range of motion is observed in all four extremities. No joint pain or stiffness,
Neurological
The patient’s speech is clear; a tone is good. The posture is erect, the balance is stable, and the gait is normal.
Psychiatric
The patient is alert and oriented. She is dressed neatly: in a jacket and jeans. The patient maintains eye contact and answers questions appropriately. Her speech is soft and clear.
Lab Tests
- Platelet – 497,000 (High).
- CBC (Hgb) – 10.7mg/dL (Low).
- RBC – 3,500,000 (Low).
- MCV – 75 femtl (Low).
- Vitamin D – 20 (Low).
- T Cholesterol – 239 (High).
Special Tests
Not special tests are available.
Diagnosis
Differential Diagnoses
- Microcytic hypochromic anemia, iron deficiency;
- Thalassemia;
- Microcytic hypochromic anemia, sideroblastic.
Diagnosis
- Microcytic hypochromic anemia, iron deficiency.
The assessment of the patient regarding the laboratory results allows for speaking about microcytic hypochromic anemia. Iron deficiency anemia is a type of microcytic hypochromic anemia that can be viewed as the main diagnosis for this case. The patient has pale skin, and her yellowish skin on palms is a symptom of microcytic anemia (MCV is decreased) (DeLoughery, 2014). The amount of hemoglobin in red blood cells determined with the help of laboratory tests is low (anemia is hypochromic) (Kafle & Lakhey, 2016). The chronic blood loss associated with gastrointestinal bleeding is one of the main causes of microcytic hypochromic anemia related to iron deficiency (Kim et al., 2014).
For thalassemia caused by inherited problems, a high level of RBC is typical. Thalassemia cannot be discussed in this case because the RBC count is low. Sideroblastic anemia is an inherited condition associated with gene mutations (Friedman et al., 2015). Laboratory test results do not provide evidence for this type of microcytic hypochromic anemia.
Plan/Therapeutics
Plan
- Further testing: gastroscopy, endoscopy, and colonoscopy; the fecal occult blood test; TIBC and reticulocyte tests.
- Medication: Vitamin B6, B12, D3, folic acid; iron supplements; Omeprazole; Loratadine; Lovastatin (10 mg/day).
- Education: controlling gastritis and iron levels.
- Non-medication treatments: a low-fat and iron-rich diet.
This plan is oriented to treating microcytic hypochromic anemia associated with iron deficiency. Thalassemia and sideroblastic anemia can be treated with help using folic acid, applying Iron Chelation therapy, conducting blood transfusions, and removing toxic agents (Friedman et al., 2015). In this case, these methods are not appropriate to be followed.
Further testing required for the case should be oriented to determining the cause of anemia to address the problem. Gastroscopy, endoscopy, and colonoscopy are important to diagnose chronic gastrointestinal bleeding that causes iron deficiency and cannot be noticed without conducting these tests. The fecal occult blood test is important to determine the amount of blood in feces. Total iron-binding capacity (TIBC) and reticulocyte tests are important to determine the amount of iron and red blood cells lost by the patient because of chronic bleeding (Camaschella, 2015). These laboratory test results are required to determine the doses of prescribed medications.
The patient should take vitamin B6, B12, D3, and folic acid, which increase hemoglobin levels. Iron supplements should be taken to address the deficiency and increase hemoglobin (Shander et al., 2014). The patient should continue taking Omeprazole and Loratadine (Teubner et al., 2015). Lovastatin should be prescribed to address hypercholesterolemia and decrease cholesterol levels.
The patient should receive education regarding the control of iron levels and symptoms of gastritis to prevent further bleeding and significant decreases in hemoglobin. Non-medication treatments include following an iron-rich and low-fat diet to decrease cholesterol and increase hemoglobin. The patient should consume meat, fish, grain products, green vegetables, beans, and nuts and avoid consuming saturated fats (Camaschella, 2015).
Follow-up
The appointment should be scheduled in 3-4 weeks for discussing test results and making additional tests.
Evaluation of the patient encounter (Self-Assessment)
This case was appropriate to help me focus on unobserved causes of health problems, which can lead to such conditions as anemia. Although the patient had no complaints associated with anemia, it was important to focus on some signs of the problem to diagnose it efficiently. Therefore, the case was helpful to learn about diagnosing and treating anemia associated with iron deficiency. The careful procedure of assessing the patient and analyzing laboratory results has allowed me to make an appropriate diagnosis to determine an effective treatment plan. Thus, while conducting assessments, I should pay attention to subjective data, collect objective data, and compare this information and symptoms with test results to determine the causes of a certain condition. This case demonstrates that a patient often does not know about his or her chronic severe conditions. Therefore, I should pay much attention to assessing this patient and his or her past medical history to determine tests to conduct and diagnoses to choose.
References
Camaschella, C. (2015). Iron-deficiency anemia. New England Journal of Medicine, 372(19), 1832-1843.
DeLoughery, T. G. (2014). Microcytic anemia. New England Journal of Medicine, 371(14), 1324-1331.
Friedman, A. J., Shander, A., Martin, S. R., Calabrese, R. K., Ashton, M. E., Lew, I.,… Goodnough, L. T. (2015). Iron deficiency anemia in women: A practical guide to detection, diagnosis, and treatment. Obstetrical & Gynecological Survey, 70(5), 342-353.
Kafle, S., & Lakhey, M. (2016). Etiological study of microcytic hypochromic anemia. Journal of Pathology of Nepal, 6(12), 994-997.
Kim, B. S., Li, B. T., Engel, A., Samra, J. S., Clarke, S., Norton, I. D., & Li, A. E. (2014). Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World Journal of Gastrointestinal Pathophysiology, 5(4), 467-478.
Shander, A., Goodnough, L. T., Javidroozi, M., Auerbach, M., Carson, J., Ershler, W. B.,… Lew, I. (2014). Iron deficiency anemia: Bridging the knowledge and practice gap. Transfusion Medicine Reviews, 28(3), 156-166.
Teubner, D., Hoffman, A., Fisseler-Eckhoff, A., Huettenhain, T., Manner, H., Kiesslich, R., & Rey, J. W. (2015). Rare gastroenterologic finding as a cause of hypochromic microcytic anemia. Deutsche Medizinische Wochenschrift, 140(20), 1539-1542.