Cardiovascular, Cellular, and Hematologic Disorders – Case Study

Part One:

INITIAL HISTORY:

Tom is a 47 year old male who presents with gradual onset of dyspnea on exertion and fatigue. He also complains of frequent dyspepsia with nausea and occasional epigastric pain. So far you only know that he has a history of alcohol abuse.

Discussion question part one:

What questions would you like to ask this patient about his symptoms?

Part Two

  He says he has not had his usual energy levels for months; dyspnea has become much worse in the last few weeks which is why he came in. Tom denies chest pain, orthopnea, edema, cough, wheezing, or recent infections. He states he has occasional episodes of hematemesis after drinking heavily, and subsequently has had several days of dark stools. Tom consumes up to 2 six-packs of beer a day for the past 8 years since losing his job. Nothing seems to make his breathing any better, but antacids help with is epigastric discomfort and dyspepsia.

PAST MEDICAL HISTORY:

Denies history of cardiac or pulmonary disease

Diagnosed with duodenal ulcer in the past and was on “3 drugs at once” for a while 2 years ago, but stopped taking them due to the expense

His only surgical history was a childhood tonsillectomy

De does not smoke or take any medications except for over the counter antacids

He has no known allergies

 

PHYSICAL EXAMINATION:

Thin and pale white male looking older than his stated age with no acute distress

T = 37 C orally; P = 95 and regular; RR = 16 and unlabored; B/P = 128/72 sitting

 

Skin, HEENT, Neck:

Skin pale without rash, no spider angiomata

Sclera pale with no icterus

PERRLA, fundi without lesions

Pharynx is clear without postnasal drainage

NO thyromegaly, adenopathy, or bruits

 

Lungs, Cardiac:

Good lung expansion, lungs clear to auscultation and percussion

PMI at 5^th intercostal space at midclavicular line

Heart rhythm regular with a grade II/VI systolic ejection murmur at left sternal border

No gallops, heaves, or thrills

 

Abdomen, Rectal:

Abdomen nondistended; bowel sounds present

Liver 8 cm. At midclavicular line

Moderate epigastric tenderness without rebound or guarding

Prostate not enlarged and nontender

Stool guaiac positive

 

Extremities, Neurological:

No joint deformity, muscle tenderness or edema

Alert and oriented X 3

Strength is 5/5 throughout and sensation intact

Gait normal.  DTR 2 + and symmetrical throughout

 

Discussion questions part two:

What are the pertinent positives and negatives on examination related to his presenting problem?

 

What is your differential diagnosis at this time?

 

What laboratory studies should be obtained at this time?

 

Part Three

LABORATORY RESULTS:

WBC = normal with a normal differential and platelet count

Hct = 29%; MCV = normal, MCHC = slightly decreased; RDW = markedly increased; reticulocyte count < 2%

Smear with mixed microcytic/hypochromic and macrocytic/normochromic red blood cells; WBC and platelets appear normal

PT/PTT, liver function tests, electrolytes, and amylase normal

Upper endoscopy with 2 cm. duodenal ulcer with evidence of recent but no acute hemorrhage

ADDITIONAL LABORATORY RESULTS:

Serum iron, total iron binding capacity, saturation, and ferritin all reduced

Bone marrow biopsy with megaloblastic changes and low iron stores

Ø  Serum folate and red blood cell folate low; B₁₂ normal

Discussion questions part three:

Based on these findings, what are the diagnoses for this patient?

How should this patient be managed?