Anemia Case Study

Chief Complaint

Fatigue

History

Emily presents to see you today with complaints of generalized weakness, lethargy and inability to do the routine work she did last month. She reports that she is having excessive bleeding during her periods over the last six months. She complains of being short of breath, and feels her heart pounding when climbs stairs in her house. She also has had light-headedness, but has not fainted. She has also noticed cramping in her legs, and states that she eats ice all the time and never used to.

ROS

She denies any fever, drug intake or abdominal discomfort. Her appetite is decreased, she eats once a day.

Allergies

NKDA

PmHx

GERD, takes ranitidine PRN

Painful menses, takes ibuprofen

Family Hx

Family history significant for HTN.

Assessment

This is a pleasant 18 y.o. female. BP of 108/68 mm Hg, HR 108, RR 14, 64 inches tall and weighs 132 lbs.

HEENT: pale gums, and her tongue was swollen

CV: S1S2 RRR, + 2/6 murmur heard best at LUSB (Left Upper Sternal Border)

Resp: CTA bilaterally A +P

Ext: pale nail beds

Labs

RBC 3.5 million/mm3
Hgb 7 g/dl
HCT 30%
MCV 67 (low)
MCHC low
Serum Iron 11 (low)
Ferritin 5 ng/mL (Low)
Total Iron Binding Capacity in the Blood (TIBC) 585ug/dL (high)

1. Describe the development and differentiation of RBCs.  Describe the 3 underlying pathophysiological causes of anemia based on RBC size? What are the consequences if left untreated?

2. How would you differentiate anemia based on laboratory findings? What are the general management recommendations for each of the 3 types of anemia described above? What are general follow-up recommendations?

3. Given the above case, complete the Assessment and Plan components of this SOAP note.  For Assessment please list the diagnoses in priority order beginning with the type of anemia and also include a nursing diagnosis. For the Plan, you need only address the anemia. Be sure to include: medications, Labs, Diagnostics, Education and Counseling, Referrals (if any), and Follow-up.

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