Clinical note · #4
Office & outpatient
Chief Complaint
Fatigue and evaluation of anemia requiring transfusion.
History of Present Illness (HPI)
78-year-old male with history of diabetes presents for evaluation of refractory anemia requiring repeated transfusions. Most recent hemoglobin noted at 7.1 g/dL.
Patient reports
No active bleeding
Prior transfusions (2 months ago and again a few weeks before that)
Symptoms: fatigue, malaise, mild dyspnea
Currently on
Vitamin B12, iron, folic acid, and erythropoietin (Procrit)
Denies
Fever, weight loss, night sweats
Bone pain, rash, arthralgia, myalgia
No lymphadenopathy reported
Past Medical History
Diabetes mellitus
Past Surgical History
Hernia repair
Medications
Warfarin (Coumadin)
Furosemide (Lasix)
Metformin
Folic acid
Diltiazem
Vitamin B12
Prevacid
Iron (Feosol)
Allergies
No known drug allergies
Social History
Tobacco use: Yes
Alcohol: Denies
Lives alone with family support
Family History
Negative for hematologic or malignant disorders
Review of Systems (ROS)
Positive: fatigue, dyspnea
Negative: bleeding, fever, night sweats, bone pain
Physical Examination
General: Alert, oriented, no acute distress
Vitals: BP 110/60, HR 99, RR 14, Temp 97.4°F
HEENT: Normal
Neck: No lymphadenopathy
Cardiovascular: Regular rate and rhythm
Respiratory: Clear to auscultation
Abdomen: Soft, non-tender, possible LUQ fullness
Extremities: Mild edema, no cyanosis
Neurologic: No focal deficit
Assessment
Refractory anemia, transfusion dependent
Suspected underlying myelodysplastic syndrome (MDS)
Diabetes mellitus (stable)
Possible renal contribution to anemia (Cr increased to 1.6)
Plan
Order
Reticulocyte count
Serum protein electrophoresis
LDH
Vitamin B12, folate
Erythropoietin level
Schedule
Bone marrow aspiration and biopsy (discussed risks/benefits; patient agreed)
Imaging
Abdominal ultrasound (evaluate splenic fullness)
Continue current medications
Follow-up after hospitalization