Chief Complaint:
Mrs. Moore is a 67-year-old female feeling tired and short of breath at times with minimal activities. She also complains of arthritic pains in her neck, back, and hands.
Review of systems:
Notable for hearing loss, dentures, glasses, and dyspnea mostly with exertion.
She has occasional palpitations of the heart and orthopnea at times. Her bowel movements are regular, and she has not noticed any blood in the stool.
She has bilateral leg swelling, which is about usual for her since she was started on amlodipine.
Screenings:
She has not had a mammogram for 5 years, and she has not had a dual energy x-ray absorptiometry scan, colonoscopy, or other preventive screenings recently.
Surgical History:
Denies any surgical procedures.
Advance Directives:
Completed advance directives (a do not resuscitate order and a living will).
Patient Medical History:
Hypertension and osteopenia
Allergies:
Sulfa drugs and penicillin
Medications:
Amlodipine besylate (Norvasc): 5 mg/day
Calcium carbonate (OsCal) with vitamin D twice daily
Physical Exam:
Appears well-nourished and groomed. She is mildly short of breath at rest but in no apparent pain or distress. She is 5 feet 6 inches tall and weighs 156 pounds. The patient is hard of hearing and wears glasses for distance and reading. Her oropharynx is clear, and her neck is supple. There is no lymphadenopathy. Lungs are diminished bilaterally with air movement.
Heart: S1-S2, Systolic 1+ murmur in the left MCL. The abdomen is soft, non-tender. BS are positive x4 quadrants. No masses palpated. She has 1+ edema to bilateral lower extremities.
Vital signs:
Blood pressure of 132/84 mm Hg; pulse 78 beats/minute; temperature 97.4 degrees F; respirations 20 breaths/minute; and oxygen saturation 92% on 2 L/minute.
Answer the following questions:
What is your differential diagnosis?
What is your working diagnosis?
Labs Results:
Complete Blood Count
RBC
3.6 million mm
Hemoglobin
12.5 g/dL
Hematocrit
36%
MCH
27 pg/cell
MCHC
33.0 g/L
MCV
88 fL
Leukocytes
5,700 cells/mcL
Serum iron
26 mcg/dL
Unsaturated iron binding capacity
216 mcg/dL
Total iron binding capacity
242 mcg/dL
Transferrin saturation
11%
Reticulocyte count
1%·
Stool for occult blood
Negative (three samples)
Chemistry profile
Normal
Answer the following questions:
Which lab values are normal, and which lab values are abnormal?
What is your differential diagnosis?
What is the diagnosis?
Explain the significance of each abnormal result?
What type of anemia (Acute or Chronic)?
What is the diagnostic criteria for the anemia?
Discuss your treatment plan (Be VERY specific)
What is your follow up?
**Provide References**
Please include in the references
Laboratory and Diagnostic Tests with Nursing Implications (Required)
Author: Joyce LeFever Kee
Publisher, Edition, Year: Boston, MA: Pearson, 10th edition
ISBN-10: 978-0134704463
ISBN-13: 9780134704463
