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Respond to the 2 following discussion posts separately with separate reference lists. Reference lists to be no older than 5 years.
1. Resel Casimiro posted Aug 11, 2022 8:52 PM
In this case study of a 55-year-old female patient who presented to the office with fatigue, she is likely suffering from iron deficiency anemia. Iron deficiency anemia or IDA is characterized by low mean corpuscular hemoglobin (MCH), low mean corpuscular hemoglobin volume (MCV), low iron, and low transferrin saturation. It is also imperative to test for serum ferritin (total iron body stores) as it is the most efficient test for IDA (DeLoughery, 2017). However, the iron-binding capacity (TIBC) value will be on the higher range (Warner & Kamran, 2022). This patient’s laboratory result demonstrates these abnormalities.
Based on the patient’s history of fatigue with no obvious blood or fluid loss, deeper interview and assessment is required to identify the underlying cause of the abnormal laboratory values. Additional questions that should be asked are: Any history of bariatric surgery? Any decrease in iron intake, change in diet, or special diet? Any history of gastrointestinal problems? Are you suffering from heavy menses? (Warner & Kamran, 2022). Further investigation must be performed depending on the patient’s answers. Some additional testing that is recommended for this patient are fecal occult blood testing, peripheral smear, H pylori, and endoscopy as these tests may direct to a diagnosis (Sonoda, 2021).
My final assessment or diagnosis for this patient is iron deficiency anemia. The pharmacological recommendations are oral daily dose of elemental iron 150-200 mg PO daily or ferrous sulfate 325 mg PO three times a day. Take the oral iron supplement with vitamin C and empty stomach to aid with absorption (DeLougherty, 2017).
Patient education will include diet rich in protein and iron, increase intake of dietary fiber due to potential constipation from iron supplements, potential blood transfusion for severe anemia, energy conservation, frequent rest periods, and nausea as a side effect from the iron supplements (Warner & Kamran, 2022).
DeLoughery, T. G. (2017). Iron deficiency anemia. The Medical Clinics of North
America, 101(2), 319–332. https://doi.org/10.1016/j.mcna.2016.09.004
Sonoda, K. (2021). Iron deficiency anemia: Guidelines from the American Gastroenterological
Association. American Family Physician, 104(2), 211–212.
Warner, M. J., & Kamran, M. T. (2022). Iron deficiency anemia. In StatPearls. StatPearls
2.Joseph Berberabe posted Aug 11, 2022 7:47 PM
For the 55-year-old woman with complaints of fatigue, in addition to asking about rectal bleeding, nausea, vomiting, and abdominal pain, I would also inquire about any underlying medical conditions, medication use, family history of anemia, dietary practices such as vegan/vegetarian diet or if she is experiencing pica, symptoms that might suggest celiac disease, gastritis, Helicobacter Pylori, whether the patient donates blood, participates in marathon running, nonsteroidal anti-inflammatory drug (NSAID) use, recent travel that may have increased her exposure to parasitic infections, and recent infections/illnesses (Auerbach, 2022a; Means & Brodsky, 2022). Due to her age, she is likely near her menopause transition, but it would be helpful to ask about menses and irregular/abnormal vaginal bleeding (Auerbach, 2022a; Means & Brodsky, 2022). I would also ask other history questions to help focus the assessment and narrow differential diagnoses such as whether the patient was exhibiting signs of hemolysis such as jaundice, dark urine, history of gallstone, exposure to oxidant drugs and foods that might cause hemolysis such as fava beans (Auerbach, 2022a; Means & Brodsky, 2022).
Based on the patient’s lab results with a low hemoglobin (Hgb) of 10.9, low red blood cell count (RBC) of 3.53, low mean corpuscular volume (MCV) of 76, low mean corpuscular hemoglobin (MCH) of 24, elevated red cell distribution width (RDW) of 19, low ferritin of 16, and low serum iron of 23, my leading diagnosis is microcytic hypochromic iron deficiency anemia (Auerback, 2022a). Because there is no indication that the patient is unable to adhere to oral iron regimen, no surgeries planned within the next two months, no indication for inflammatory bowel disease, no history of gastrectomy or bariatric surgery, and is not dialysis-dependent, the patient is a candidate for oral iron (Auerbach, 2022b). For this patient, I would recommend alternate day dosing versus daily dosing as her levels are just outside of normal, there is less likelihood of severe constipation or gastrointestinal toxicity, and no indication of complex anemia and/or other compounding comorbidities (Auerbach, 2022b). Furthermore, evidence shows that aggressive iron repletion can potentially decrease iron absorption (Auerback, 2022b). I would engage in shared decision making based on the patient’s preference, but if the patient agrees to alternate day dosing, I would prescribe Ferrous Sulfate 324mg, taken orally one hour before meal or two hours after meal on Mondays, Wednesdays, and Fridays (Auerback, 2022b).
I would inform the patient that side effects to oral iron are common and include constipation, metallic taste, nausea, vomiting, flatulence, diarrhea, itching, and black/green or tarry stools (Auerback, 2022b). I would instruct the patient to contact clinic if these side effects occur as the medication might need to be changed to a formulation with less elemental iron and/or discuss the necessity of adding a stool soften (Auerback, 2022b). The patient should also be encourage the patient to increase dietary fiber to promote tolerability encouraged to eat foods with high sources of iron such as meat, fish, poultry, tofu, lentils, and kale (Auerback, 2022b). The patient should be given a fecal immunochemical test (FIT) kit and instructed to bring the kit back to clinic as soon as possible to test for occult blood and necessity for further workup (Auerback, 2022a) and be scheduled for follow up in two weeks to assess tolerability of treatment and recheck labs in four to eight weeks (Auerback, 2022b).
Auerbach, M. (2022a). Cause and diagnosis of iron deficiency and iron deficiency anemia (Means, R.T., Elmore, J.G., Tirnauer, J.S., & Kunnis, L., Eds.). UpToDate. https://www.uptodate.com/contents/causes-and-diagnosis-of-iron-deficiency-and-iron-deficiency-anemia-in-adults?sectionName=DIAGNOSTIC%20EVALUATION&search=anemia%20algorithm&topicRef=7133&anchor=H23&source=see_link#H23
Auerbach, M. (2022b). Treatment of iron deficiency anemia in adults (Mentzer, W.C.,Means, R.T., Tirnauer, J.S., & Kunnis, L., Eds.). UpToDate.
Means, R.T., & Brodsky, R.A. (2022). Diagnostic approach to anemia in adults (Mentzer, W.C., Tirnauer, J.S., & Kunnis, L., Eds.). UpToDate. https://www.uptodate.com/contents/diagnostic-approach-to-anemia-in-adults?search=anemia%20algorithm&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1