Iron Deficiency Anemia: 47-Year-Old Male Patient Case Study

Important questions to help explore patient’s disease symptoms

The first step in treating the patient’s condition may involve understanding his family history, history of drug use and amount of alcohol consumed per day (Springhouse, 2006). In addition, the patient should be grilled on any pre-existing mental disorder, metabolic conditions, cardiac problems and medication regimen as well as his sleep patterns. More so, it is wise to ask the patient if he ever suffered any head injury in the past and have him describe his smoking habits. Furthermore, he should be asked to explain the condition he is complaining of (dyspepsia) in relation to meals and the effects of remedies taken. Finally, the practitioner may inquire if the patient is undergoing any stress.

Important questions to help explore the patient’s medical history

The case presented may warrant a medical practitioner to ask about the patient’s critical diseases history and major hospitalizations. The caregiver should inquire about past hematologic setbacks, past surgeries and liver problems as well as breeding abnormalities (Collins, 2003).

In addition, many want to know the patient’s family history, recent medications and bleeding duration. Furthermore, it is recommended to ask if the bleeding is associated with shock and whether the patient bruises easily. Moreover, caregivers should ask about any case of petechie and renal or splenic disease. Finally, a medical officer may want to know whether the patient is allergic. This is done by considering past treatment using drugs like chloramphenicol which are known to cause allergy (Springhouse, 2006). Then, both physical and diagnostic procedures may be taken.

Abnormal and normal findings in the physical examination

Physical tests carried out on the patient revealed several abnormal conditions. General physical examination indicated that the patient had a thin pale coloration and he appeared older than the stated age even though he suffered no stress. Furthermore, the patient’s sclera was pale although it lacked icterus and his mouth’s corner had signs of cheilosis. In addition, his nails were brittle and thin in appearance. Finally, abdominal and rectal tests showed the presence of moderate epigastric tenderness and guaiac positive stool. These are the physical manifestation of anemia (Coya & Lash, 2009). Nevertheless, there were some encouraging results.

The patient had a standard body temperature (37° Celsius) and a normal pulse rate (95 beats per min). In addition, respiratory rate was normal (16 breaths per minute) while the blood pressure was typical at 120/72 mmHg (Coya & Lash, 2009). The patient’s pupils were equal, round and reactive to light and his pharynx was clear and without any postnasal drainage. More encouraging results indicated that the patient suffered no cases of thyromegaly, adenopathy, or bruits.

Moreover, the client had good bilateral lung expansion and lungs were clear to auscultation. More so, the heart rate was proved to be all right although there was a grade II/VI systolic murmur at the left sternal border. Any cases of gallops, heaves or thrills were dispelled. In addition, the patient’s abdomen was non-distended and the liver span was 8cm at the midclavicular line. His prostate was healthy and he seemed to have stamina. Finally, he had normal body strength (5/5), intact sensation, normal gait, and he had deep tendon reflexes that were 2+ and symmetric throughout. After the physical tests, diagnostic procedures were carried out and their findings are interpreted below.

Interpretation of diagnostic findings

The patient’s hemoglobin was shown to be 8 g/dl instead of 13-18g/dl for normal men (Springhouse, 2006). This means that there was less oxygen in circulation. In addition, Mean Corpuscular Volume (MCV) was normal and this condition may exist in a normocytic anemia. Additionally, the patient’s Mean Corpuscular Hemoglobin Content (MCHC) was slightly decreased. This is associated with conditions like microcytic anemia and it is attributed to factors such as iron deficiency, chronic blood loss and thalassemia (Springhouse, 2006). Moreover, the red cell distribution width was markedly increased while the MCV was normal.

This presented possible cases of early stages of iron deficiency, vitamin B deficiency, and early folate deficiency as well as initial stages of the anemic condition. The diagnostic results also showed mixed microcytic/hypochromic and macrocytic/normochromic red blood cells. The findings can be associated with folate and iron deficiencies (Springhouse, 2006). This condition may also be responsible for normal MCV. The appearance of platelets was normal hence their function in blood clotting was not jeopardiz