Iron Deficiency Anemia
Age: years old
Gender:
HISTORY:
Presents for anemia
Lab results:
Hb , Ferritin , B12 , TSH , creatinine , CRP ,
Associated symptoms: *Try using right-click for negatives*
, up to °, over
, over
, , ,
, , , clots
Contributing factors:
no history of: , , , , , , , ,
no use of: , , , ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: conjunctiva/sclera , lids/lashes , cornea , , extraocular movements , OD 20/, OS 20/
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Anorectal: DRE , prostate , , , anus
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: iron deficiency anemia, vitamin B12 deficiency, folate deficiency, anemia of chronic disease, hemolytic anemia, sickle cell anemia, thalassemia, aplastic anemia, myelodysplastic syndromes, chronic kidney disease, hypothyroidism, lead poisoning, alcoholism, gastrointestinal bleeding, bone marrow infiltration (e.g., leukemia, lymphoma), autoimmune diseases, liver disease, infection, chemotherapy, nutritional deficiencies, hemoglobinopathies, hereditary spherocytosis, G6PD deficiency
PLAN:
Investigations:
- Blood work: , , , , , , , , , , , , , , ,
- Stool:
- Abdominal ultrasound
- Upper GI endoscopy
- Colonoscopy
- Capsule endoscopy
Treatments:
-
-
-
-
-
- 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)
Further care:
- Repeat blood work in : ,
- Referral to gastroenterologist
- Referral to hematologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as chest pain, shortness of breath, or dizziness
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: