1). Identifying data

Name: M.A.

Age: 42

Ethnicity: Caucasian

Sex: Female

Chief complaint

“For the past two months, I have been feeling tired. My appetite is very poor, and sometimes I feel dizzy. I have heavier periods and bouts of severe headaches.”

 

2. Subjective Dat

a). History of present illness

The patient in question reports low energy levels, shortness of breath when performing activities, loss of appetite, and difficulty in concentrating, dizziness, heavier periods, and headaches. Fatigue is reduced by rest and but nothing soothes the problems.

 

 

1. b) Current health status

M.A. has no known allergies. She intends to get a flu vaccine today. The patient does no drugs or drinks and does not smoke. She is heterosexual but has not been sexually active for the past six months. She is currently receiving treatment for hypertension, but she says that it has been three years since her last pap smear and physical examination. She reports that she tries to eat healthily, but due to her busy schedule, her diets mostly consist of fast foods and take outs. She states that she enjoys playtime with her children, but the fatigue, dizziness, shortness of breath and headache does not allow time for that.

1. c) Past medical history

Beside her hypertension, the patient states that she is generally in good health. She has had two hospitalizations for vaginal deliveries. She hasn’t had any surgeries, fractures, fractures, or childhood illnesses.

1. d) Social history

M.A. is a single mother of two boys who resides in Riverdale County. She works as a sales rep at a clothing store. The patient says that she receives financial help from her sister who lives in the county. Her children’s father helps by paying child support. She considers her Catholic faith to be an essential factor to which she is and feels that her spirituality will help in her medical care.

1. d) Family history

• Father- alive with HTN history receiving medication
• Mother-Alive with HTN and DM. Receiving medication
• Sister-Alive with no medical condition
• Children-Alive with no medical complication

1. e) Systems review

General: Healthy overall

Head/Eyes: Presence of headaches, no change in vision, eye pain.

Cardiovascular: No chest pain or palpitations

Respiratory: Present shortness of breath

Gastrointestinal: No nausea, diarrhea, vomiting, or abdominal pain

Female: LMP was 9/2/19, G3T2D0F2. Placed under IUD 3 years ago for birth control

Musculoskeletal: No back pain, muscle weakness, numbness, or joint pains

Neurological: No change in sight, taste, hearing, or smell

Psychiatric: No history of anxiety or depression

Hematologic: Denies easy bruising or bleeding. Heavy periods

3. Objective Data
4. a) BP: 124/96 T: 96.7 F P: 81    R: 18    O₂ Sat: 100% on RA     Ht: 5’5”    Wt: 192 Ibs

General: Alert, no acute distress, well-groomed, obese

HEENT: PERRLA, MMM, head norm cephalic, neck supple, clear oropharynx-no lesion; no enlarged lymph nodes, Slight periorbital edema noted, No cervical lymphadenopathy or tenderness,  Thyroid midline firm without palpable masses.

 

Cardiac: RRR, normal S1/S2

Pulmonary: symmetrical chest expansion

Skin: no rash, pink and moist

Diagnostic: HgbAlc-10.1.

4. Assessment

Medical diagnosis

1. a) Differential diagnosis

Iron Deficiency Anemia (D50.9)- Iron deficiency anemia indicated by diminished production of red blood cell due to low iron stores. It is a common nutritional disorder that accounts for half of the cases. Causes include inadequate iron intake, heightened iron demand by the body, low iron absorption, and increased iron loss. Anemia is indicated by the hemoglobin level of two standard deviations below normal for age and sex (Short &Domagalski, 2013). A CBC to provide information about the cause and degree of anemia; Hemoglobin and Hematocrit levels reflect the degree of anemia. Total Iron-Binding capacity (TIBC) should be increased in iron deficiency anemia since although the ability to bind with iron is high; hemoglobin is low in both MCV and MCHC.

 

 

 

 

5. Plan

 

M.A. seems to be suffering from iron deficiency anemia. According to Short and Domagalski (2013), White females above the age of 20 should have a hemoglobin level of 12.7 or higher than 80. M.A. falls below these numbers with anHgb of 10.1 and MCV of 74.1. Ferritin levels should be drawn to diagnose iron deficiency anemia officially. Ferritin is the most appropriate test as it shows iron stores.Ferritin levels below 15 ng per mL indicate iron deficiency anemia.

 

Diagnostics:

1. CBC: WBC 8 Hgb 10.1 Hct33 RBC 3.2 MCV 74 MCHC 27.8 RDW 18.1
2. TSH:6.5mIU/L  antithyroid antibodies: 1:1,800
3. Check Free T4 level
4. Ferritin Level

Rx:Prescribe if Free T4 is low-primary hypothyroidism. Prescribe Ferrous Sulfate if ferritin level is less than 15.

Education: Patient to be educated about the causes, signs, and symptoms of iron deficiency anemia as well as treatment options. Iron supplements should be administered regularly together with vitamin C rich foods such as orange juice and food to help reduce stomach upset.

Referral/Consults: Refer to an endocrinologist in case of high Free T4.

Follow Up:Return on a subsequent day to draw the Ferritin level to fully evaluate iron deficiency anemia and start treatment (Gaitonde, Rowley &Sweeney, 2012).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

Dains, J. E., Baumann, L. C., & Scheibel, P. (2015).Advanced Health Assessment & Clinical Diagnosis in Primary Care-E-Book.Elsevier Health Sciences.

 

Gaitonde, D., Rowley, K., Sweeney, L. (2012). Hypothyroidism: An update. Am Fam

Physician, 86(3):244-251. Retrieved from http://www.aafp.org/afp/2012/0801/p244.html

 

Short, M., &Domagalski, J. (2013). Iron deficiency anemia: Evaluation and management. Am Fam Physician, 87(2):98-104.Retrieved from http://www.aafp.org/afp/2013/0115/p98.html

 

Williams, M. S. (2017). Utilizing Evidence-Based Practice to Reduce Hemoglobin A1c Levels in Primary Care by Increasing the frequency of Office Visits.

 

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