The 50-Year-Old Patient Evaluation & Management Plan

 

 


A 50-year-old woman presents to the office with complaints of excessive fatigue and shortness of breath after activity, which is abnormal for her. The woman has a history of congestive heart failure with decreased kidney function within the last year. The woman appears unusually tired and slightly pale. Additional history and examination rules out worsening heart failure, acute illness, and worsening kidney disease. The CBC results indicate hemoglobin is 9.5 g/dL, which is a new finding, and the hematocrit is 29%. Previous hemoglobin levels have been 11 to 13g/dL. The patient’s vital signs are temperature 98.7°F, heart rate 92 bpm, respirations 28 breaths per minute, and blood pressure 138/72. The practitioner suspects the low hemoglobin level is related to the decline in kidney function and begins to address treatment related to the condition.

 

Discuss the following:

Which test(s) should be performed to determine whether the anemia is related to chronic disease or iron deficiency, and what would those results show?
Should the practitioner consider a blood transfusion for this patient? Explain your answer.
Which medication(s) should be considered for this patient?
What considerations should the practitioner include in the care of the patient if erythropoietic agents are used for treatment?
What follow-up should the practitioner recommend for the patient?

 

Sample Answer

 

 

 

 

 

 

 

 

 

This 50-year-old woman presents a classic scenario of anemia in the context of chronic illness, specifically congestive heart failure (CHF) and decreased kidney function. The new finding of hemoglobin (Hb) at 9.5 g/dL, a significant drop from her previous levels, warrants prompt investigation and management.

 

1. Tests to Determine Anemia Etiology (Chronic Disease vs. Iron Deficiency)

 

To differentiate between Anemia of Chronic Disease (ACD), Iron Deficiency Anemia (IDA), or a combination of both (which is common in Chronic Kidney Disease - CKD), the following iron studies should be performed:

Serum Ferritin:

What it is: Ferritin is a protein that stores iron. It is the best indicator of the body's total iron stores. However, it is also an acute phase reactant, meaning its levels can be elevated in the presence of inflammation, infection, or chronic disease (like CHF or CKD), even if iron stores are low.

Expected Results:

Iron Deficiency Anemia (IDA): Very low (typically <30 ng/mL, or even <10-15 ng/mL).

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