Question

A 52-year-old woman presents with complaints of weakness and fatigue, although she has continued to work. She attributes the complaints to menopause. Her menstrual cycles have been irregular but occasionally heavy. She has experienced a recent weight loss of 10 lbs over the past 6 months without diet or exercise. She reports chronic arthritis in her hands and knees, which is treated with Ibuprofen 400 mg when needed; mild dyspnea on exertion, chronic constipation, and HTN for which she takes diuretics. Her last mammogram was 8 months ago with normal findings and she has had no colorectal screening. She took oral contraceptives for 10 years but is currently not receiving hormonal therapy. Neurologic: confusion, slow to respond to questions, generalized weakness Cardiovascular: Blood pressure 132/86, HR 82 and regular Pulmonary: Respiratory rate 22 per minute Additional findings: Patient is pale and thin WBC 5200 Hgb 7.5 Het 26 Plt 650 Ferritin 8 Stool is + for occult blood What additional information would be beneficial in making a diagnosis? What diagnosis do you suspect? What physical assessment findings support your analysis? Which laboratory results support your analysis? What additional lab or diagnostic tests would be indicated? Discuss the pathophysiology of the suspected diagnosis What risk factors does this patient have that are associated with the diagnosis? What are the treatment options? What referral, if any, would you recommend? What discharge teaching would you include?

Answer 1

Some of the additional information which can aid in diagnosis are

• Symptoms like tachycardia, brittle nails,sore in oral cavity, headache
• Assess for neurological status of the patient for alertness,conscious, orientation ,drowsiness, concentration, etc.,
• Eating habit whether craving to eat odd objects (pica)

The suspected diagnosis is iron deficiency anaemia (can be diagnosed by very low haemoglobin, low ferritin and high platelets )

The physical assessment which support the diagnosis are

• Weakness
• Fatigue
• Mild dyspnea on exertion
• Chronic constipation

The laboratory report which support the analysis are

• Hemoglobin :Decreased (12 to 15g/dl)
• Platelet :Increased ( 15 to 4.5 /mcl)
• Ferritin:Decreased (12 to 150mg/dl)
• Hematocrit:Decreased (37 to 48%)

The additional lab or diagnostics tests which can be done are

• Serum iron level
• Serum transferrin
• Total iron binding capacity
• Endoscopy to rule out any internal bleeding in gastrointestinal tract
• Ultrasound of uterus

The pathophysiology of this disease is

When there is lack of iron in the body it leads to decreased absorption of oxygen by the cells >microcytic hypochromia>difficulty in breathing>d ecreased metabolic absorption >constipation>bleeding in the internal gastrointestinal tract,urinary system >decreased appetite >weight loss>extreme fatigue and weakness

The risk factors are

• Menstruation
• Poor intake
• Oral contraceptives used
• Medication (ibuprofen )

The treatment are

• Iron supplements
• Diet rich in iron
• Intravenous iron injection
• Blood transfusions

The reference can be provided to

• Hematologist
• Gastroenterologist
• Orthopaedic (arthritis )
• Gynaecologist (menopause)
• Neurologists (confusion )

The following discharge advice to be given

• Proper diet
• Taking medication as prescribed
• Avoiding OTC medication
• Regular follow up