Mrs XB Complains of Shortness of Breath and Fatigue

1 Mrs XB Complains of Shortness of Breath and Fatigue 6550-Week 9 Presentation Mrs. XB is a 34-year old female who presented with a chief complaint of shortness of breath and fatigue.

History of Presenting Illness XB presents with major fatigue and shortness of breath that has been persistent for about two months now. She describes her shortness of breath as progressive over the last two months.

In the beginning, she could feel it only when walking up an elevated place. Currently, it can even occur when she is at rest. She is suspecting a pregnancy but has not tested yet, insisting that she should do it with her husband, who is on a travel trip. She does not associate the shortness of breath or fatigue with chest pains or palpitations. Physically intensive activities seem to exacerbate her symptoms, while rest does not give complete comfort.

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2 Other associated signs and symptoms that she noted include numbness and tingling of the extremities and an episode of dizziness that prompted her to seek medical care. She denies changes in appetite or bowel movement. She cannot remember her last menstrual period but feels that her periods are abnormally late.

Positive and Negative Physical Exam Findings The patient appeared alert and oriented. Her vital signs indicated a regular heart rate of 83, elevated blood pressure of 163/80, normal respiratory rate, body temperature, and body mass index. Reported symptoms include shortness of breath, fatigue, and dizziness. On the review of systems, general progressive fatigue was reported with no significant neuro, cardiovascular, abdominal, genitourinary, skeletal, or GIT symptoms.

Past Medical and Surgical History The patient denies having any significant medical issues in a long time. She has never had any surgery or blood transfusions before. She is up to date with all the required vaccinations.

Current Medications She is not on any current medication.

Diagnostic Results The diagnostic tests ordered included a full blood count, serum ferritin levels, serum iron levels, vitamin B 12 levels, total iron-binding capacity (TIBC), fecal occult blood test, peripheral blood film test, urinalysis, kidney, and liver function tests. In full blood count, all the parameters were within the normal ranges except for Hb (9.8g/dL), HCT (31%), and MCV (70fl), which were below the normal ranges. Serum iron and serum ferritin levels were both below the normal range, while TIBC levels were high. Blood tests were all normal for the liver and kidney function of the 12, fecal occult blood, urinalysis, and fecal occult blood. Peripheral blood film showed

3 poikilocytosis and microcytotic red cells. The patient declined to take a pregnancy test until her next visit.

Differential Diagnosis The differential diagnosis considered in Mrs. XB’s case included iron deficiency anemia, vitamin B12 deficiency anemia, and pneumonia. The diagnosis made for the patient was iron deficiency anemia, which was supported by laboratory findings of low serum iron and ferritin levels with elevated TIBC. Iron is essential in RBCs production, and its deficiency causes low Hb and RBC levels, hence anemia. Iron deficiency anemia presents with similar symptoms of fatigue and shortness of breath. Several factors place a patient at higher risk of developing irondeficiency anemia, including low dietary iron intake, blood loss, poor dietary iron absorption, and increased iron demand in growing children, pregnant, and breastfeeding mothers. In this case, the patient is suspected to be in her first trimester, hence having increased iron demand met by dietary intake.

Vitamin B 12 deficiency anemia presents similarly to iron deficiency anemia. It is caused by dietary deficiency, poor absorption, and increased body demands for vitamin B 12. Like iron, vitamin B 12 is essential for RBC production, and its deficiency leads to anemia. The normal vitamin B12 levels rule out vitamin B12 deficiency. Pneumonia was considered as one of the differential diagnoses due to symptoms of shortness of breath and fatigue. Pneumonia is mostly caused by bacteria, viruses, or fungi and affects the lower respiratory tract. This diagnosis was not supported in this patient due to normal WBC differentials in full blood count. The patient also does not have other respiratory symptoms such as coughs and chest pains, or fevers. A chest x-ray would be done to rule out pneumonia completely.

Treatment Plan

4 She started oral iron therapy using FeSO4 325mg QD and folic acid 0.4 mg PO QD. The patient’s anemia should improve with iron supplementation, and therefore, blood transfusion is not supported at this point. In addition to medications, diet education was done. The patient was encouraged to include iron-rich foods in her diet. She was also educated on her leading a healthy lifestyle by increasing physical activeness and taking balanced meals. A follow-up visit was set after 2 weeks for the patient to get a pregnancy test done in the absence of menstrual periods and follow-up HB, folic acid, and serum iron levels tests.