Bertie Bridges iHuman Fatigue

Reason for encounter

Fatigue

History of present illness (HPI)

Bertie Bridges is an 86-year old female with underlying osteoarthritis, constipation, hypertension, GERD, and hypercholesterolemia who presents today for evaluation of a 2-month history of generalized weakness and worsening fatigue. She also reports a 2-month history of mild dyspnea, palpitations and longstanding constipation. She acknowledges feeling tired both with rest and activities like walking around the block or going up the stairs. She feels relaxed when she wakes up in the morning but gets more tired as the day progresses. The SOB has progressively been worsening, relieved mildly with rest and worsens with activity. Yesterday about half an hour after her water aerobics class, she experienced a racing heart episode which she got relief with resting after the class. She informs that her constipation has been longstanding for several years and she still strains during bowel movements. She uses a colon cleanser which initially provided relief but does not help now. She denies chills, fevers, chest pain, blood in stools, swelling in face, lower, or upper extremities, or change in the shape of stools.

Physical Exam

Blood pressure
Pulse
Respiration
Temperature
SPO2
Inspect eyes
Inspect skin overall
Palpate neck
Palpate all lymph nodes
Percuss anterior & posterior chest
Auscultate lungs
Measure JVP(jugular venous pressure)
Palpate for PMI (point of maximal impact)
Auscultate heart
Visual inspection – anterior & posterior chest
Orthostatic blood pressure(BP)
Assess cranial nerves
Sensory tests(light, touch, pain, position, temperature, vibration)
Test strength
Assess gait & stance
Reflexes – deep tendon.

Case Problem Statement

The patient is an 86-year old female with a history of HTN, CAD, S/P CABG 8 years ago who was at baseline 6 months ago but presents with an acute episode of tachycardia and dyspnea without chest pain, that started during routine exertion. She also has a 2 month history of progressive fatigue, generalized weakness, and mild dyspnea on exertion. She is normotensive, tachycardic (HR=110) with a flow murmur but negative for fluid overload. ROS only positive for constipation.

Plan

Diagnosis feedback – iron deficiency anemia

The cause of the patient’s iron deficiency anemia needs to be established in the elderly the most common cause is due to GI blood loss. The cause of the blood loss includes:

Gastritis
Ulcer
Colon cancer
Diverticuli
Angiodysplasia

The incidence of gastritis and ulcers is higher in those individuals taking NSAIDs. Colon cancer is routinely screened for up to age 75 but beyond that age the screening of older individuals’ remains controversial. However, the onset of occult blood loss resulting in iron deficiency anemia, colon cancer should be part of her causal work-up.

Assessment plan

Abd CT with contrast to evaluate for colon cancer
EGD was done for her reflux symptoms and possible risk for esophageal malignancy

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