Chief cpc-2

Case History
Department of Internal Medicine
47 y/o AAF presents for further evaluation of anemia. She has a 6 month Clinicopathologic Conference
h/o transfusion dependent anemia. She is followed at a community hospital by hematology and has been refractory to PO iron, IM B12, and SQ darbopoietan. Two bone marrow examinations over the past 6 March 14, 2013
months have been reported as “nondiagnostic”. She also reports a several year history of recurrent nausea and vomiting with a few occasions of scant hematemesis. She denies any other history of gastrointestinal bleeding. She admits strict compliance with her 47 year old female with paresthesias and transfusion
medications. She does use Goody’s Powder regularly but denies use of any other over the counter medications, herbals or vitamins. Over the dependent anemia
last several weeks, she has noted numbness and tingling of her hands and feet. She denies any focal weakness, gait instability, or falls. She denies any back pain. She does report a seven pound weight loss over the past six months which she feels is due to nausea. Denies Past Medical History:
o transfusion dependent (2 units q 2-3 months) over past 6 o history of iron deficiency 20 years ago, resolved with o history of B12 deficiency, resolved with monthly IM B12 o s/p partial gastrectomy (bilroth 2) in early 80’s with History of recurrent gastrointestinal bleeding o occasion hematemesis associated with episodes of o h/o lower GI bleed s/p right hemicolectomy in 1990 Menorrhagia: s/p hysterectomy in early 90’s ROS:Negative
Family History:
v Three healthy children, no history of anemia or hematologic abnormality. Maternal aunt with laryngeal cancer Social History:
Laboratory Data and Imaging
Chemistries are all within normal limits. WBC 2.1 (18%N, 47%L, 20%M, Employed as a nursing assistant, lives in an older home in north LFTs unremarkable including albumin of 3.4 Allergies:
Peripheral smear: mild anisopoikilocytosis, rare hyperlobulated neutrophil, absolute netropenia with relative eosinophilia and Medications:
BM aspirate and bx: erythrocytes show megaloblatic changes with appropriate sequential maturation, granulocytes left shifted with sequential maturation. Cytoplasmic vacuolization in erythroid and granulocytic progenitors. Megakaryocytes present with some small hypolobulated forms. No increased blasts. Iron stain is normal with Physical Exam
ringed sideroblasts. 50% cellularity on biopsy, no lymphoid aggregates. Impression of this and the previous two BM examinations at CGH: This Vital Signs: T:96.4 P: 98 BP: 128/93 R: 16 Sat: 98% RA Ht: 5 ft, 2
A diagnostic test was performed and a diagnosis was made. GEN: mild bitemporal wasting, no acute distress Normal hair pattern, no alopecia HEENT: anicteric sclera, pale conjunctiva, mucosal membranes moist NECK: supple, no LAN, no thyromegaly CHEST: clear to auscultation, no rhonchi/wheezes/rales CV: regular rhythm, nl S1/S2, no S3 or S4, 2/6 midsystolic murmur ABD: well healed midline scar, nml BS, no palpable mass or hepatosplenomegaly NEURO: CN’s intact, strength 5/5 and symmetric bilaterally, sensation intact to light touch, two-point discrimination, decreased vibratory sensation at medial malleolus, decreased bilateral

Source: http://www.intmed.vcu.edu/docs/CPC_Protocol_031313.pdf