Mrs. Garcia a 62 year old female with a history of chronic
gastritis presents today to your primary care office with complaints of
weakness, fatigue, burning sensation in the tongue, paresthesias to bilateral
lower extremities, and memory loss. Patient reports symptoms began more than 3
months ago. She admits to drinking 1 bottle of wine on a daily basis to “relax
her nerves”.
Patient Medical History:
Hypertension, osteopenia, chronic gastritis
Review of Systems
Uses glasses for distance and reading. Hard of hearing.
Occasional episodes of short term memory loss. Fatigue and short of
breath when laying down and with exertion at times. She has occasional
palpitations. Reports her bowel movements are normal and denies any melena or
blood in the stool.
Screenings:
Mammogram and colonoscopy are up to date and were all
unremarkable. Dual energy x-ray absorptiometry scan shows osteopenia.
Surgical History:
Denies any surgical procedures.
Allergies:
NKDA
Medications:
Omeprazole 20 mg po daily
Calcium carbonate (OsCal) with vitamin D twice daily
Physical Exam:
Appears disheveled, thin and frail. Skin is pale. Bilateral
conjunctivae appear pale. She is mildly short of breath at rest but in no
apparent pain or distress. She is 5 feet 2 inches tall and weighs 100 pounds.
The patient wears glasses for distance and reading. Her oropharynx is clear,
and her neck is supple. There is no lymphadenopathy. Lungs are clear. Heart:
S1-S2, Systolic 2+ murmur in the left MCL. The abdomen is soft, non-tender. BS
are positive x4 quadrants. No masses palpated. Decreased sensitivity to
bilateral lower extremities
Vital signs:
Blood pressure of 100/72 mm Hg; pulse 90 beats/minute;
temperature 97.4 degrees F; respirations 20 breaths/minute; and oxygen
saturation 93%.
Answer the following questions:
1. What is your differential diagnosis?
2. What is your working diagnosis?
You then order labs and these are the results on the subsequent
visit:
Complete Blood Count
RBC
3.2 million/microliter
Hemoglobin
10.5 g/dL
Hematocrit
32%
MCH
41 microliter
MCHC
42%
MCV
115
microliter
Leukocytes
5,700 cells/mcL
Serum iron
90 mcg/dL
Total iron binding capacity
300 mcg/dL
Transferrin
250 mg/dL
Reticulocyte count
0.3%
Stool for occult blood
Negative (three samples)
Chemistry profile
Normal
Answer the following
questions:
1. Which lab values are normal, and which lab
values are abnormal?
2. Explain the significance of each abnormal
result?
3. What type of anemia does this patient most
likely have and what further lab(s) would you order to confirm your diagnosis?
4. Discuss your treatment plan if the lab(s)
ordered to confirm the diagnosis are positive. (Be specific to your diagnosis).
5. What is your follow up?
**Provide
References**
