Cardiovascular, Cellular, and Hematologic Disorders - Case Study
Part One:
INITIAL HISTORY:
Tom is a 47 year old male who presents with gradual onset of dyspnea on exertion and fatigue. He also complains of frequent dyspepsia with nausea and occasional epigastric pain. So far you only know that he has a history of alcohol abuse.
Discussion question part one:
What questions would you like to ask this patient about his symptoms?
Part Two
He says he has not had his usual energy levels for months; dyspnea has become much worse in the last few weeks which is why he came in. Tom denies chest pain, orthopnea, edema, cough, wheezing, or recent infections. He states he has occasional episodes of hematemesis after drinking heavily, and subsequently has had several days of dark stools. Tom consumes up to 2 six-packs of beer a day for the past 8 years since losing his job. Nothing seems to make his breathing any better, but antacids help with is epigastric discomfort and dyspepsia.
PAST MEDICAL HISTORY:
Denies history of cardiac or pulmonary disease
Diagnosed with duodenal ulcer in the past and was on "3 drugs at once" for a while 2 years ago, but stopped taking them due to the expense
His only surgical history was a childhood tonsillectomy
De does not smoke or take any medications except for over the counter antacids
He has no known allergies
PHYSICAL EXAMINATION:
Thin and pale white male looking older than his stated age with no acute distress
T = 37 C orally; P = 95 and regular; RR = 16 and unlabored; B/P = 128/72 sitting
Skin, HEENT, Neck:
Skin pale without rash, no spider angiomata
Sclera pale with no icterus
PERRLA, fundi without lesions
Pharynx is clear without postnasal drainage
NO thyromegaly, adenopathy, or bruits
Lungs, Cardiac:
Good lung expansion, lungs clear to auscultation and percussion
PMI at 5th intercostal space at midclavicular line
Heart rhythm regular with a grade II/VI systolic ejection murmur at left sternal border
No gallops, heaves, or thrills
Abdomen, Rectal:
Abdomen nondistended; bowel sounds present
Liver 8 cm. At midclavicular line
Moderate epigastric tenderness without rebound or guarding
Prostate not enlarged and nontender
Stool guaiac positive
Extremities, Neurological:
No joint deformity, muscle tenderness or edema
Alert and oriented X 3
Strength is 5/5 throughout and sensation intact
Gait normal. DTR 2 + and symmetrical throughout
Discussion questions part two:
What are the pertinent positives and negatives on examination related to his presenting problem?
What is your differential diagnosis at this time?
What laboratory studies should be obtained at this time?
Part Three
LABORATORY RESULTS:
WBC = normal with a normal differential and platelet count
Hct = 29%; MCV = normal, MCHC = slightly decreased; RDW = markedly increased; reticulocyte count < 2%
Smear with mixed microcytic/hypochromic and macrocytic/normochromic red blood cells; WBC and platelets appear normal
PT/PTT, liver function tests, electrolytes, and amylase normal
Upper endoscopy with 2 cm. duodenal ulcer with evidence of recent but no acute hemorrhage
ADDITIONAL LABORATORY RESULTS:
Serum iron, total iron binding capacity, saturation, and ferritin all reduced
Bone marrow biopsy with megaloblastic changes and low iron stores
Ø Serum folate and red blood cell folate low; B12 normal
Discussion questions part three:
Based on these findings, what are the diagnoses for this patient?
How should this patient be managed?