Patient Profile
D.G. is a 72-year-old man who has recently experienced the loss of his wife six months ago. Concerned about his father’s deteriorating health, his daughter brings him to the healthcare provider for evaluation. D.G. has a history of hyperlipidemia and is currently prescribed niacin-lovastatin 500/20 mg orally (PO) once daily at bedtime.
Subjective Data
According to the patient’s report, several subjective symptoms and observations have been noted: Fatigue: D.G. has been experiencing unusual tiredness for the past few months. This persistent fatigue suggests a decline in his overall energy levels. Shortness of breath and palpitations: The patient frequently experiences shortness of breath and describes sensations of his heart pounding. These symptoms may indicate underlying cardiovascular issues that require further investigation. Weight loss: D.G. has lost weight recently, which can be attributed to his altered eating patterns since the passing of his wife. Previously, his wife took care of the cooking, and he has been unable to maintain proper nutrition by cooking himself.
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Dietary habits: The patient describes his typical daily meals as coffee and a donut for breakfast, a hot dog and lemonade for lunch, and a jelly sandwich on white bread and coffee for supper. This dietary pattern lacks variety and may not provide the necessary nutrients for maintaining good health. Considering the subjective data provided, it is evident that D.G.’s physical and emotional well-being has been significantly affected since the loss of his wife. His fatigue, shortness of breath, and weight loss warrant further investigation to determine the underlying causes and develop an appropriate management plan that addresses his nutritional needs and emotional well-being.
Physical Examination
During the physical examination, the following objective data were observed:
- Blood pressure: 118/72 mmHg, indicating a regular blood pressure reading.
- Pulse: 98 beats per minute, within the normal range.
- Temperature: 98.2°F (36.8°C), implying an average body temperature.
- Respirations: 16 breaths per minute, within the normal range.
- Oxygen saturation: 92% on room air, slightly lower than the optimal range.
- Height: 5’6″ (167.6 cm), providing information about the patient’s stature.
- Weight: 135 lb (61.2 kg), indicating the patient’s current weight.
- BMI: 21.7 kg/m², within the normal range, suggesting a healthy body mass index.
- S1 and S2 heart sounds were auscultated and found to be regular.
- Bilateral radial pulses were palpated and found to be +3 and regular, indicating solid and equal vibrations on both sides.
- Lungs were clear bilaterally upon auscultation, suggesting normal respiratory function.
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Diagnostic Studies
The diagnostic studies yielded the following results:
- Red Blood Cell count (RBC): 3,300,000/μL, indicating a significantly low red blood cell count.
- Hemoglobin: 8.3 g/dL, which is lower than the normal range, suggesting the presence of anemia.
- Hematocrit: 24%, confirming the diagnosis of anemia as it falls below the expected range.
- Mean Corpuscular Volume (MCV): 73 fL, indicating microcytic red blood cells, a characteristic of certain types of anemia.
- Mean Corpuscular Hemoglobin (MCH): 23 pg, further supporting the diagnosis of microcytic anemia.
- White Blood Cell count (WBC): 9,100/μL, within the normal range, suggesting a normal immune response.
- Platelet count: 250,000/μL, within the normal range, indicating normal blood clotting function.
- Iron: 28 mcg/dL, potentially indicating low iron levels.
- Ferritin: 14 ng/mL, below the expected range, may suggest iron deficiency.
- Cobalamin (Vitamin B12): 600 pg/mL, within the normal range.
- Folate: 10 ng/mL, within the normal range, suggesting adequate folate levels.
Based on the objective data obtained from the physical examination and diagnostic studies, the patient exhibits signs of anemia characterized by low red blood cell count, decreased hemoglobin and hematocrit levels, and microcytic red blood cells. Additionally, the patient’s oxygen saturation is slightly below the optimal range. Further investigation and interpretation of these findings are necessary to identify the underlying cause of the anemia and develop an appropriate treatment plan.
Discussion Questions
Interpreting D.G.’s laboratory results reveals several concerning findings. The low red blood cell count (RBC) indicates the presence of anemia, likely caused by bleeding. Additionally, the low hemoglobin level is consistent with anemia. The decreased hematocrit is also attributed to over-hydration. The mean corpuscular volume (MCV) value, which measures the average size of red blood cells, suggests the presence of microcytic anemia. Furthermore, the low mean corpuscular hemoglobin (MCH) level indicates a deficiency in the protein found in red blood cells. These results, along with the low iron and ferritin levels, suggest iron-deficiency anemia.
NR 324 Week 4 Monday Case Study
Based on the laboratory data and assessment findings, D.G. is diagnosed with iron-deficiency anemia. Clinical manifestations of this condition in D.G. include excessive fatigue reported over the past few months, which can be attributed to decreased hemoglobin levels. Poor dietary choices and weight loss further indicate malnutrition, which can result from iron deficiency and contribute to the severity of the illness. A reduced number of red blood cells in the blood characterizes iron-deficiency anemia. Red blood cells carry oxygen throughout the body, and hemoglobin, an iron-rich protein, binds to oxygen in the lungs. This type of anemia is commonly caused by insufficient iron intake. In D.G.’s case, his inadequate dietary choices and potentially impaired iron absorption from his medication contribute to his anemia. Treatment for iron-deficiency anemia involves prescribing iron supplements and incorporating iron-rich foods into the diet.
In D.G.’s teaching, it is essential to include dietary sources of iron. He should have iron-rich foods in his diet: dark leafy greens, spinach, salmon, lean red meat, and eggs. When teaching patients taking oral iron supplements, it is crucial to highlight that the supplements should be taken on an empty stomach. Taking them with a small amount of food can help alleviate potential cramps. Additionally, consuming foods high in vitamin C can enhance iron absorption, while raw vegetables and caffeine should be avoided during iron supplement intake. To determine whether D.G.’s anemia is resolving, evaluative parameters such as follow-up lab tests, including complete blood count (CBC), serum ferritin level, blood iron level, vitamin B12, and folate levels, can be used to monitor the progress and improvement of his condition.
