Posted: September 7th, 2022

Assessing, Diagnosing, and Treating Hematological and Immune System Disorders

Assessing, Diagnosing, and Treating Hematological and Immune System Disorders

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Assessing, Diagnosing, and Treating Hematological and Immune System Disorders
Affected person Info:
Initials – GL Age – 73 Intercourse – M Race – Black-American
73-year-old affected person
S (subjective)
CC: The affected person got here to the clinic complaining of anemia and gentle thrombocytopenia for 5 months.
HPI: GL is a 73-year previous Black-American male affected person who involves the clinic complaining of anemia and gentle thrombocytopenia. The situation has lasted 5 months. Consumer denies of any blood loss. The shopper is experiencing fatigue and lack of weight. She denies experiencing fever, jaundice, and pruritus. Different observations embrace dark-colored urine and bleeding. The shopper is taking Hyzaar, however it has minimal impact.
Present Medicines:
1. Glyburide 5mg BID.
2. Zocor 40 mg QD.
three. Digoxin zero.15 mg QD.
four. Hyzaar QD
Allergy symptoms: NKDA
PMHx:
1. Anemia and gentle thrombocytopenia, each lately recognized, atrial fibrillation, kind 2 diabetes, hyperlipidemia, and congestive coronary heart failure.
Soc and Substance Hx:
He labored in anesthesiology division earlier than retiring. Along with the spouse they’ve three youngsters. He’s a former pipe smoker however denies ingesting
Fam Hx: The grandmother suffered from kind 2 diabetes earlier than dying. The daddy had Parkinson’s and the mom succumbed to previous age problems at 84. Her sister has bronchial asthma, CHF, plus weight problems.
Surgical Hx: No historical past of surgical operations.
Psychological Hx: No historical past of analysis with melancholy, nervousness, or suicidal ideation.
Violence Hx: No historical past of violence or sexual abuse.
Reproductive Hx: Has three youngsters within the 1970s.
ROS (Assessment of signs):
GENERAL: No unintentional weight reduction or acquire, fatigue, chills, fever, or weak spot.
HEENT:
• Eyes: No visible loss, double imaginative and prescient, or yellow sclera.
• Ears, Nostril, Throat: No listening to issue, nasal congestion, working nostril, or sore throat.
SKIN: No pores and skin rashes, dry plaques, or lesions.
CARDIOVASCULAR: No edema, chest tightness or tightness, or chest ache.
RESPIRATORY: No cough, or shortness of breath.
GASTROINTESTINAL: No vomiting or diarrhea.
GENITOURINARY: No ache throughout urination or pressing must cross urine. Pink-colored urine.
NEUROLOGICAL: No seizures, dizziness and inconsistent in bowel or bladder management.
MUSCULOSKELETAL: No stiffness, muscle, again, or joint ache,
HEMATOLOGIC: No anemia, bruising, or bleeding.
LYMPHATICS: No historical past of enlarged nodes.
PSYCHIATRIC: No historical past of melancholy or nervousness.
ENDOCRINOLOGIC: No historical past of chilly or warmth intolerance.
REPRODUCTIVE: Not sexually lively.
ALLERGIES: NKDA.
O (goal)
Bodily examination:
Very important indicators: B/P 124/83, Pulse 66, Temp 98.07F orally, RR 18, non-labored, SpO2: 96 room air, H 5’2, W 120lbs.
Neurological: A&O * four. The affected person is current, acutely aware of time and place, and cooperative. His gown code is match for the occasion.
HEENT: Normocephalic and atraumatic. No conjunctiva erythema. Oropharynx crimson.
Neck: No swelling, JVD, or trachea midline.
Chest/lungs: Clear to auscultation bilaterally.
Coronary heart: No murmurs or palpitation. Common coronary heart rhythm.
ABD: Smooth and tender.
Genital/Rectal: Common bladder and bowel management.
Musculoskeletal: No deformities or joint issues.
Pores and skin: small crimson spots. Dry and heat with no lesions and gentle bruising.

Diagnostic outcomes:
CBC take a look at to examine the variety of blood cells. It measures blood cells’ ranges, together with crimson and white blood cells and platelets (Hanai et al., 2016).
A (Assessment)
Differential diagnoses:
Anemia and Gentle Thrombocytopenia
Iron deficiency anemia is the most important explanation for anemia. It results in inadequate crimson blood cells to hold oxygen within the physique (Wulff et al., 2018). The situation may be gentle or extreme, everlasting, or short-term. It makes sufferers really feel weak and drained. Different signs embrace shortness of breath, dizziness, crimson spots on the pores and skin, and bleeding gums (Wulff et al., 2018). The key causes of anemia embrace blood loss and the physique’s incapability to supply crimson blood cells. Sicknesses can destroy crimson blood cells. Anemia can result in thrombocytopenia, characterised by abnormally low platelets (Wulff et al., 2018). The causes of low ranges of platelets embrace underlying medical circumstances and unintended effects of remedy. Therapy will rely on the underlying circumstances and analysis (Wulff et al., 2018). A number of the frequent types of therapies embrace oxygen, oral and intravenous fluids, and ache relievers. Analysis includes a CBC take a look at.
Bone Marrow Failure
Bone marrow failure is a uncommon illness involving the lack to make ample blood, particularly crimson blood cells that carry oxygen. The situation may be inherited or acquired. A number of the situation signs embrace fatigue, shortness of breath, and irregular coronary heart fee. Others embrace pale pores and skin, and extended bleeding from cuts (Valka & Cermak, 2018). Analysis contains bone marrow biopsy and blood checks.
Evan’s Syndrome
Evan’s syndrome is an autoimmune illness through which the immune system destroys the crimson blood cells. The illness signs embrace fatigue, light-headedness, and paleness (Valka & Cermak, 2018). Analysis includes exclusion by ruling out different potential circumstances.
Aplastic Anemia
The situation happens when the physique ceases creating new blood cells. It results in fatigue and exposes sufferers to different sicknesses. A number of the signs embrace shortness of breath, pale pores and skin, and extended sicknesses (Buttarello, 2016). Analysis contains bone marrow biopsy and blood checks.

The first analysis is anemia and gentle thrombocytopenia.

P (plan)
Sufferers ought to take elaborate diagnostic checks to ascertain the illness. Therapy of anemia and gentle thrombocytopenia includes ache relievers. Different types of remedy embrace a blood transfusion. Relying on the analysis, the affected person could require intravenous or oxygen help (Buttarello, 2016). A affected person would require common Assessment to make sure the affected person’s situation is bettering. A follow-up go to to the clinic is crucial to make sure the affected person’s situation isn’t deteriorating (Buttarello, 2016). The remedy plan ought to embrace a eating regimen plan that can prescribe how the affected person ought to take meals to enhance vitality and power.
The reflection exhibits that the affected person is affected by anemia and gentle thrombocytopenia as a result of numerous components. Aged sufferers are more likely to expertise weaknesses as a result of superior age. One other lesson is that anemia can co-exist with thrombocytopenia. The complication can set off signs that have an effect on the standard of life and every day actions of sufferers. The remedy of anemia and thrombocytopenia depends upon the analysis of the trigger and different underlying components. The analysis requires an elaborate Assessment of the situation to make sure applicable remedy.
Additional Assessment of the affected person’s medical historical past is important to generate the suitable analysis. It’s going to set up the underlying circumstances that require medical consideration to eradicate the dangers related to anemia. The affected person ought to learn to establish the signs and report for a medical analysis earlier than deterioration.
Way of life adjustments can assure the advance of the situation. A number of the adjustments embrace consuming a nutritious diet and ingesting ample water. Sufferers ought to keep away from predisposing components and proceed treating different circumstances that will set off the illness (Wulff et al., 2018). The aged affected person could require dietary supplements to help the physique.

References
Buttarello, M. (2016). Laboratory analysis of anemia: are the previous and new crimson cell parameters helpful in classification and remedy, how?. Worldwide Journal of Laboratory Hematology, 38, 123-132.
Hanai, Y., Matsuo, Ok., Ogawa, M., Higashi, A., Kimura, I., Hirayama, S., … & Yoshio, T. (2016). A retrospective research of the chance components for linezolid-induced thrombocytopenia and anemia. Journal of An infection and Chemotherapy, 22(eight), 536-542.
Valka, J., & Cermak, J. (2018). Differential analysis of anemia. Vnitrni Lekarstvi, 64(5), 468-475.
Wulff, J., Margolin, J., Coleman, N. E., Demmler-Harrison, G., Lam, F., & Shah, M. D. (2018). A extreme case of murine typhus presenting with anemia and extreme thrombocytopenia. Journal of Pediatric Hematology/Oncology, 40(three), 185-190.

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Tags: and Treating Hematological and Immune System Disorders, Assessing, Diagnosing