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Iron Deficiency Anemia Case Study

Iron Deficiency Anemia Case Study

Description

Iron Deficiency Anemia

Patho/Pharm Case Study

Reason for Seeking Care

“I feel weak and tired lately.”

HEALTH HISTORY

HPI

B.S. is a 28 year old white female who reports a 2 month history of menorrhagia, intermenstrual bleeding, extreme fatigue, and weakness. Her menstrual period occurs every 28 days. Lately, she’s had 6 days of heavy flow and cramping. She denies abdominal distension and back pain. She reports that her energy level has not returned to normal since her last pregnancy.

PMH

G5P5T5A0. Four pregnancies in past four years. Fourth child delivered via SVD four months ago. All deliveries were without complications. All children were born and remain healthy.

Three year history of osteoarthritis of the left knee. History of left knee trauma in MVA at age 9. Reports that she takes ibuprofen 3 tabs daily for pain. She has been taking it for 2.5 years. She recently doubled her daily dose due to increasing pain with decreased relief.

Three year history of HTN treated with antihypertensive medication.

No history of surgeries.

Family History

Father living, age 66, stable angina.

Mother living, 58, osteoarthritis.

Brother, 35, living with DM2 and hyperlipidemia.

Sister, 32, depression and hypothyroidism.

Paternal grandparents deceased, heart disease.

Maternal grandparents unknown due to adoption.

Children, aged 4 months, 12 months, 2-1/ years, 4 years, 9 years. All healthy.

Social History

Born in US to Greek immigrants.

Married, homemaker. Lives with husband of 10 years.

Denies smoking, alcohol intake, street drug use.

Lacto-ovo vegetarian x 5 years.

Admits to lack of regular exercise program, “although the kids keep me running all the time.”

ROS

Craves cold celery x 3 weeks

+ mild urinary urgency with incontinence

+ mild SOB with exertions, difficulty concentrating

Denies hematuria, hematemesis, hemoptysis, melena

Denies palpitations, history of cardiac or pulmonary disease

Medications

OTC ibuprofen 200 mg po 6x/day prn

OTC omeprazole 20 mg po QD

HCTZ 30 mg po BID

Denies vitamin, calcium, and iron supplements.

Allergies

Erythromycin causes upset stomach

ASA causes upset stomach

PHYSICAL EXAM

General Survey

Tired and pale looking white overweight female in NAD. Appears her stated age. Pleasant, cooperative, alert & oriented x3.

Vital Signs

T = 98.0 F; P = 140 and regular; RR = 17 and easy; BP = 100/40 (seated, right arm)

HT = 5’6”

WT = 173 lbs

Significant PE Findings

Skin pale, cool

Sclera bluish, conjunctiva pale

Oral mucous membranes pale

Tachycardic, systolic murmur heard best at RSB

Joint enlargement and limited ROM of left knee consistent with DJD.