Subjective:

  • Chief Complaint: The patient is a 45-year-old female presenting with persistent fatigue and generalized weakness over the past three months. She describes the fatigue as a constant, dull tiredness that does not improve with rest.
  • History of Present Illness: The patient reports worsening fatigue that now interferes with her daily activities. She also mentions intermittent headaches and a 10-pound unintentional weight loss over the past two months. The patient denies changes in diet, exercise, or recent travel. She has been feeling more stressed at work recently but denies any significant life changes.
  • Past Medical History: Significant for hypertension, managed with lisinopril, and hyperlipidemia, treated with atorvastatin. There is no known family history of chronic diseases such as diabetes or cardiovascular disease.
  • Social History: The patient is a non-smoker, consumes alcohol occasionally, and works as a school teacher. She reports increased work-related stress due to recent curriculum changes.
  • Review of Systems: Positive for fatigue, headaches, and unintentional weight loss. Negative for fever, night sweats, chest pain, dyspnea, palpitations, or gastrointestinal symptoms.
Objective:
  • Vital Signs: Blood pressure: 130/85 mmHg, Heart rate: 78 beats per minute, Respiratory rate: 16 breaths per minute, Temperature: 98.6°F.
  • General: The patient appears slightly pale but is in no acute distress.
  • Cardiovascular: Normal heart sounds, regular rhythm, no murmurs, rubs, or gallops detected.
  • Respiratory: Lungs are clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
  • Abdominal: Soft, non-tender, no hepatosplenomegaly, no masses, bowel sounds present in all quadrants.
  • Neurological: Cranial nerves II-XII intact, no focal neurological deficits.
  • Other: Mild pallor noted in the conjunctivae, slight tachycardia observed.
Assessment:
  • Final Diagnosis: Iron Deficiency Anemia.
  • Rationale: The patient’s fatigue, pallor, and weight loss, combined with the laboratory findings of low hemoglobin, hematocrit, and serum ferritin levels, support the diagnosis of iron deficiency anemia. The presence of microcytic, hypochromic red blood cells on the CBC further corroborates this diagnosis. The thyroid function tests were within normal limits, ruling out hypothyroidism, and the PHQ-9 score was low, suggesting that depression is not a primary factor in this case.
Plan:
  1. Treatment:
    • Iron Supplementation: Start the patient on oral iron supplements, such as ferrous sulfate 325 mg once daily, to replenish iron stores. Recommend taking the supplement with vitamin C to enhance absorption.
    • Dietary Modifications: Advise the patient to increase dietary intake of iron-rich foods such as red meat, leafy green vegetables, and fortified cereals.
  2. Follow-Up:
    • Schedule a follow-up appointment in four weeks to reassess hemoglobin levels and monitor for improvement in symptoms. Adjust the iron supplementation dosage if necessary.
    • Monitor for potential side effects of iron supplementation, such as gastrointestinal discomfort or constipation.
  3. Further Evaluation:
    • Investigate possible sources of chronic blood loss, such as gastrointestinal bleeding, which may require referral to a gastroenterologist for endoscopic evaluation if indicated.
    • Assess menstrual history to rule out menorrhagia as a contributing factor.
  4. Patient Education:
    • Educate the patient on the importance of adherence to the iron supplementation regimen and dietary changes. Explain that improvement in symptoms may take several weeks.
    • Discuss potential side effects of iron supplementation and strategies to mitigate them (e.g., taking iron with food to reduce gastrointestinal upset).
  5. Mental Health:
    • Although the PHQ-9 score was low, provide the patient with resources for managing stress, such as relaxation techniques, and consider a referral to counseling if work-related stress continues to be a concern.
References: