Hematological Disorder (Episodic Case Write Up)
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Hematological Disorder (Episodic Case Write Up)
Chief Complaint
The patient complains of weakness, fatigue, shortness of breath, and dizziness.
History of Present Illness HPI
The patient (Mrs. Johnson) is a 36-year-old Caucasian female who lives with her husband and two daughters. The patient bled for three months after she began using injectable birth control. The bleeding stopped one week ago following a change in her type of birth control. She says other symptoms began three days ago and she fears might become severe. The patient, the husband, and the two daughters live together in one apartment on the outskirts of the town. The patient states that she has only one male sexual partner. She says she does not use a condom since she is married.
Past Medical History
The patient has had a history of hypertension for the past four years. She believes her condition (hypertensive) is inherited from her mother. She currently takes simvastatin and Niacin to manage hypertension. Additionally, the patient was admitted two years ago with cases of excessive bleeding and anemia after she was involved in a mild accident. During this time, the patient was also diagnosed with depression, which was managed through counseling and Zoloft. Present, the patient does not take any medication apart from simvastatin and Niacin for hypertension.
Past Surgical History: The patient does not have any past surgical history. She says she has never had any cesarean delivery.
Allergies:
There are no known drug allergies. However, the patients claim that she is allergic to red meat. She often eats red meat after taking antihistamine medications.
Family History
The patient’s mother has hypertension, which she developed at the age of 30. She is now 50 years old and on similar medications (simvastatin and Niacin) to manage her condition. Mrs. Jonson says her father developed diabetes at age 62. The patient’s husband does not have any chronic condition. Additionally, the two daughters are healthy with no medication.
Medications: Simvastatin and Niacin
Social History:
The patient is married to a Lecturer in one of the most prominent or recognized universities in the US. The patient herself is working as a nurse in a large hospital. The patient’s husband takes moderate alcohol. Mrs. Jonson denies either smoking or taking alcohol or illicit drugs.
Review of Systems (ROS)
Constitutional symptoms: The patient admits a feeling of weakness, fatigue, and dizziness. She has also complained of vaginal bleeding for three months now. She experiences difficulty sleeping, weight loss, and loss of appetite.
Eyes- She denied blurred vision, ocular pain, difficulty focusing, peripheral visual changes, diplopia, scotoma, and dry eyes. Her last eye examination was in April of 2016.
Ears, nose, mouth, and throat– Mrs. Johnson denies headaches, vertigo, sinus problems, oral lesions, hoarseness, epistaxis, dental problems, hearing difficulty, and nasal congestion.
Cardiovascular– Patient denies any heart murmur, palpitations, chest pain, dyspnea, varicose veins, activity intolerance, edema.
Respiratory– Patient denies cough. She denies difficulty breathing, SOB on exertion wheezing, pain on inspiration. She also refused exposure to passive smoke, exposure to TB, hemoptysis, history of respiratory infections. Mrs. Johnson states she has never had a chest x-ray. Her last TB skin test was done in June 2015and it was negative.
Gastrointestinal– The patient denies difficulty swallowing and heartburn. She admits to the loss of appetite. She denies nausea, vomiting, bloating, constipation, epigastric pain, and hematemesis. She denied hematochezia, change in bowel habits, abdominal or epigastric pain, food intolerance, flatulence, and hemorrhoids.
Genitourinary– She denies dysuria, incontinence, and heavy bleeding. She says she had the first period at age 14. She has never had a history of irregular monthly periods before this episode. She states to have just one partner.
Musculoskeletal- Patient denies, swelling, muscle cramps or pain, joint pain, and neck pain/stiffness.
Integumentary: Denies skin rashes, itching, hair loss, nail deformity, moles, open areas, or bruising. Denies breast lumps, discharge, pain, or dimpling during a breast examination.
Neurologic- Patient denies numbness, muscular weakness, transient weakness, involuntary movements or tremors, syncope, stroke, tingling, memory difficulties, seizures, paresthesia.
Psychiatric- Patient denies mood changes nightmares, anxiety, depression, mood changes, nervousness, suicidal thoughts, insomnia and exposure to violence, or excessive anger.
Endocrine– Patient denies cold or heat intolerance, polydipsia, thyroid problems, polyphagia, hair or nail texture. She admits unexplained change in weight, polyuria. She admits pale, and changes in facial or body hair.
Hematologic/lymphatic– The patient admits to irregular vaginal bleeding for months but has now stopped. She admits to weakness, fatigue, and dizziness.
Allergic/immunologic– The patient admits to being allergic to red meat. Additionally, she denies being allergic to drugs.
Physical Exam (PE)
Temperature: 98.8 °F. The temperature is within the normal range.
Respiratory: 32 per minute
Blood pressure: 85/52 BMI: 18.1
Weight: 16.0kg
Height: 96cm
General: unbalanced and fussy.
Skin: Warm and no rashes. Pale skin.
Eyes: The patient has a normal eyesight strength of 20/40 in each eye.
Ears: denies fluid discharge or swelling.
Nose: There is no lesion or asymmetry. The mucosa is pink; normal color.
Mouth/Throat: No tonsils and no exudate in the pharynx.
Neck: no presence of rigidity
Abdomen: normal liver and spleen.
Genital: vaginal bleeding.
Labs
Pap Smear: Negative result
Wet Prep: Normal
Complete Blood Count (CBC): 8 g/dL (120 g/L), hematocrit 34%, RBC 3 million/mcL
Pregnancy test: negative
Diagnosis
Anemia
Based on the results of the complete blood count (CBC), the patient was diagnosed with anemia. According to Lanier et al. (2018), anemia occurs when hemoglobin levels are less than 12 g/dL in women. In the CBC results, the patient had 8g/dL, indicating the presence of anemia (Joosten, 2018). Additionally, people who have anemia exhibit a red blood count (RBC) that is less than 4 million/mcL. In this regard, the patient also indicated anemia. According to Lanier et al. (2018), symptoms of anemia include weakness, fatigue, shortness of breath, and dizziness.
Intervention
The patient developed iron deficiency due to blood loss. Pharmacologic treatments involve taking iron supplements. According to Lanier et al. (2018), ion replacement is used as a treatment as long as there are no negative impacts of the drugs. For instance, oral therapy with ferrous sulfate 325 mg, three times per day is recommended. The dose is expected to achieve between 100 and 200 mg of elemental iron daily (Lanier et al., 2018). Vitamin B12 and folate can be used to replace oral therapy.
Apart from pharmacologic treatments, patient education will be necessary to ensure adherence and proper use of medications. For instance, oral iron supplements such as ferrous sulfate 325 should not be taken along with food due to a potential of reduced absorption (Chaparro & Suchdev, 2019). Nutritional education is also important for the patient to know the type of food she needs to take. For example, she should take foods such as liver, lean meat, vegetables, fruits, and others.
References
Chaparro, C. M., & Suchdev, P. S. (2019). Anemia epidemiology, pathophysiology, and etiology in low‐and middle‐income countries. Annals of the New York Academy of Sciences, 1450(1), 15-31. https://doi.org/10.1111/nyas.14092
Joosten, E. (2018). Iron deficiency anemia in older adults: A review. Geriatrics & gerontology international, 18(3), 373-379. https://doi.org/10.1111/ggi.13194
Lanier, J. B., Park, J. J., & Callahan, R. C. (2018). Anemia in older adults. American family physician, 98(7), 437-442. https://www.aafp.org/afp/2018/1001/p437.html