Anemia

HISTORY:

Presents for ‍newknown anemia



Lab results:

Hb ‍

Ferritin ‍, B12 ‍, TSH ‍, creatinine ‍, CRP ‍, ‍

‍fatigue

‍shortness of breath

‍dizziness

‍pale skin

‍fever

‍unexplained weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍hematochezia, ‍bright reddark red, ‍around stoolsmixed with stools, ‍withwithout clots

‍dark, tarry stools

‍heavy menstrual bleeding



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: -R: ‍normal, -L: ‍normal, ‍

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Anemia ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍reticulocyte count, ‍ferritine, ‍iron studies, ‍vitamin B12, ‍folate, ‍TSH, ‍creatinine, ‍CRP, ‍ESR, ‍LDH, ‍haptoglobin, ‍direct antiglobulin test, ‍peripheral blood smear, ‍serum protein electrophoresis, ‍anti-transglutaminase

- Stool: ‍fecal occult blood test

- Abdominal ultrasound

- Upper GI endoscopy

- Colonoscopy

- Capsule endoscopy

- ‍Iron supplements

- ‍Vitamin B12 supplements

- ‍Folic acid supplements

- ‍Erythropoiesis-stimulating agents

- ‍Blood transfusion

- Increase dietary intake of iron-rich foods (meat, fish, poultry, legumes, green leafy vegetables, iron-fortified cereals)

- Increase dietary intake of vitamin B12-rich foods (meat, fish, poultry, eggs, dairy products)

- Repeat blood work in ‍ ‍weeksmonths: ‍CBC, ‍feritin

- Referral to gastroenterologist

- Referral to hematologist

- Follow-up in ‍ ‍daysweeksmonths

- Return if symptoms worsen or if new symptoms develop such as chest pain, shortness of breath, or dizziness