Assessing, Diagnosing, and Treating Hematological and Immune System Disorders
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Assessing, Diagnosing, and Treating Hematological and Immune System Disorders
Patient Information:
Initials – GL Age – 73 Sex – M Race – Black-American
73-year-old patient
S (subjective)
CC: The patient came to the clinic complaining of anemia and mild thrombocytopenia for five months.
HPI: GL is a 73-year old Black-American male patient who comes to the clinic complaining of anemia and mild thrombocytopenia. The condition has lasted five months. Client denies of any blood loss. The client is experiencing fatigue and loss of weight. She denies experiencing fever, jaundice, and pruritus. Other observations include dark-colored urine and bleeding. The client is taking Hyzaar, but it has minimal effect.
Current Medications:
1. Glyburide 5mg BID.
2. Zocor 40 mg QD.
3. Digoxin 0.15 mg QD.
4. Hyzaar QD
Allergies: NKDA
PMHx:
1. Anemia and mild thrombocytopenia, both recently diagnosed, atrial fibrillation, type 2 diabetes, hyperlipidemia, and congestive heart failure.
Soc and Substance Hx:
He worked in anesthesiology department before retiring. Together with the wife they have three children. He is a former pipe smoker but denies drinking
Fam Hx: The grandmother suffered from type 2 diabetes before dying. The father had Parkinson’s and the mother succumbed to old age complications at 84. Her sister has asthma, CHF, plus obesity.
Surgical Hx: No history of surgical operations.
Mental Hx: No history of diagnosis with depression, anxiety, or suicidal ideation.
Violence Hx: No history of violence or sexual abuse.
Reproductive Hx: Has three children in the 1970s.
ROS (review of symptoms):
GENERAL: No unintentional weight loss or gain, fatigue, chills, fever, or weakness.
HEENT:
• Eyes: No visual loss, double vision, or yellow sclera.
• Ears, Nose, Throat: No hearing difficulty, nasal congestion, running nose, or sore throat.
SKIN: No skin rashes, dry plaques, or lesions.
CARDIOVASCULAR: No edema, chest tightness or tightness, or chest pain.
RESPIRATORY: No cough, or shortness of breath.
GASTROINTESTINAL: No vomiting or diarrhea.
GENITOURINARY: No pain during urination or urgent need to pass urine. Pink-colored urine.
NEUROLOGICAL: No seizures, dizziness and inconsistent in bowel or bladder control.
MUSCULOSKELETAL: No stiffness, muscle, back, or joint pain,
HEMATOLOGIC: No anemia, bruising, or bleeding.
LYMPHATICS: No history of enlarged nodes.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No history of cold or heat intolerance.
REPRODUCTIVE: Not sexually active.
ALLERGIES: NKDA.
O (objective)
Physical exam:
Vital signs: B/P 124/83, Pulse 66, Temp 98.07F orally, RR 18, non-labored, SpO2: 96 room air, H 5’2, W 120lbs.
Neurological: A&O * 4. The patient is present, conscious of time and place, and cooperative. His dress code is fit for the event.
HEENT: Normocephalic and atraumatic. No conjunctiva erythema. Oropharynx red.
Neck: No swelling, JVD, or trachea midline.
Chest/lungs: Clear to auscultation bilaterally.
Heart: No murmurs or palpitation. Regular heart rhythm.
ABD: Soft and tender.
Genital/Rectal: Regular bladder and bowel control.
Musculoskeletal: No deformities or joint problems.
Skin: small red spots. Dry and warm with no lesions and mild bruising.
Diagnostic results:
CBC test to check the number of blood cells. It measures blood cells’ levels, including red and white blood cells and platelets (Hanai et al., 2016).
A (assessment)
Differential diagnoses:
Anemia and Mild Thrombocytopenia
Iron deficiency anemia is the major cause of anemia. It leads to insufficient red blood cells to carry oxygen in the body (Wulff et al., 2018). The condition can be mild or severe, permanent, or temporary. It makes patients feel weak and tired. Other symptoms include shortness of breath, dizziness, red spots on the skin, and bleeding gums (Wulff et al., 2018). The major causes of anemia include blood loss and the body’s inability to produce red blood cells. Illnesses can destroy red blood cells. Anemia can lead to thrombocytopenia, characterized by abnormally low platelets (Wulff et al., 2018). The causes of low levels of platelets include underlying medical conditions and side effects of medication. Treatment will depend on the underlying conditions and diagnosis (Wulff et al., 2018). Some of the common forms of treatments include oxygen, oral and intravenous fluids, and pain relievers. Diagnosis involves a CBC test.
Bone Marrow Failure
Bone marrow failure is a rare disease involving the inability to make sufficient blood, especially red blood cells that carry oxygen. The condition can be inherited or acquired. Some of the condition symptoms include fatigue, shortness of breath, and irregular heart rate. Others include pale skin, and prolonged bleeding from cuts (Valka & Cermak, 2018). Diagnosis includes bone marrow biopsy and blood tests.
Evan’s Syndrome
Evan’s syndrome is an autoimmune disease in which the immune system destroys the red blood cells. The disease symptoms include fatigue, light-headedness, and paleness (Valka & Cermak, 2018). Diagnosis involves exclusion by ruling out other possible conditions.
Aplastic Anemia
The condition occurs when the body ceases creating new blood cells. It leads to fatigue and exposes patients to other illnesses. Some of the symptoms include shortness of breath, pale skin, and prolonged illnesses (Buttarello, 2016). Diagnosis includes bone marrow biopsy and blood tests.
The primary diagnosis is anemia and mild thrombocytopenia.
P (plan)
Patients should take elaborate diagnostic tests to establish the disease. Treatment of anemia and mild thrombocytopenia involves pain relievers. Other forms of treatment include a blood transfusion. Depending on the diagnosis, the patient may require intravenous or oxygen support (Buttarello, 2016). A patient will require regular assessment to ensure the patient’s condition is improving. A follow-up visit to the clinic is essential to ensure the patient’s condition is not deteriorating (Buttarello, 2016). The treatment plan should include a diet plan that will prescribe how the patient should take meals to improve vitality and strength.
The reflection shows that the patient is suffering from anemia and mild thrombocytopenia due to various factors. Elderly patients are likely to experience weaknesses due to advanced age. Another lesson is that anemia can co-exist with thrombocytopenia. The complication can trigger symptoms that affect the quality of life and daily activities of patients. The treatment of anemia and thrombocytopenia depends on the diagnosis of the cause and other underlying factors. The diagnosis requires an elaborate assessment of the condition to ensure appropriate treatment.
Further analysis of the patient’s medical history is necessary to generate the appropriate diagnosis. It will establish the underlying conditions that require medical attention to eliminate the risks associated with anemia. The patient should learn how to identify the symptoms and report for a medical evaluation before deterioration.
Lifestyle changes can guarantee the improvement of the condition. Some of the changes include eating a healthy diet and drinking sufficient water. Patients should avoid predisposing factors and continue treating other conditions that may trigger the disease (Wulff et al., 2018). The elderly patient may require supplements to support the body.
References
Buttarello, M. (2016). Laboratory diagnosis of anemia: are the old and new red cell parameters useful in classification and treatment, how?. International Journal of Laboratory Hematology, 38, 123-132.
Hanai, Y., Matsuo, K., Ogawa, M., Higashi, A., Kimura, I., Hirayama, S., … & Yoshio, T. (2016). A retrospective study of the risk factors for linezolid-induced thrombocytopenia and anemia. Journal of Infection and Chemotherapy, 22(8), 536-542.
Valka, J., & Cermak, J. (2018). Differential diagnosis of anemia. Vnitrni Lekarstvi, 64(5), 468-475.
Wulff, J., Margolin, J., Coleman, N. E., Demmler-Harrison, G., Lam, F., & Shah, M. D. (2018). A severe case of murine typhus presenting with anemia and severe thrombocytopenia. Journal of Pediatric Hematology/Oncology, 40(3), 185-190.
