Patient Journey Form/ GP and public health block
Student’s name: Ranad Saad Alamri Date: 7/ 10/2021
PHC center: PHC Al-Azhari
Clinical tutor name and signature: ........................................
Patient demographic:
A 25 year old Saudi female patient. Single. Lives in Madinah. A student.
Patient background:
the patient not known to have any medical illness.
Case introduction: One sentence introduction to the case (Problem representation):
she presented to the PCH with progressive weakness, fatigue and headache for 2 months.
Possible differential diagnosis: For each differential diagnosis write down what with and what
against in this case:
Iron deficiency anemia
Anemia of chronic illness
Hypothyroidism
Diagnosis:
Iron deficiency anemia
Key point in history:
Pertinent positives and negatives/ always think in the significance of each point in the diagnosis
For chronic cases you should mention points in relation to (aggravating factors, complications,
hospitalizations, self-monitoring, other risks, compliance to medications, lifestyle modification)
History of Presenting Complaint:
This is a 25-year-old woman with no past medial history presented to the PCH with
progressive weakness, fatigue and headache. The headache was in the frontal lobe. Dull in
character. Not associated with photophobia or phono phobia. These symptoms had begun about a
2 month earlier, and she no longer felt well enough to do her housework or study as the past. 3
days earlier she had dizziness, regular and rapid palpitation, Tinnitus and dyspnea with exertion.
She suffers from Menorrhagia last 5 months. She experienced previous faint about 4 months ago.
She took Panadol to relive the headache. The headache and fatigue increase with work. She says
her symptoms was sever and she give it 10/10. She had no history of jaundice, fever, anorexia,
weight loss, heat intolerance, anxiety, heartburn or diarrhea. No history of infection or blood
loss. No history of strange cravings (ice, dirt, starch). No history of gastric ulcer, malabsorption
or liver and kidney disease. No history of using aspirin or NSAIDS.
Past medical/drug history:
No history of similar condition before. No history of chronic disease like, DM, HTN, Asthma or
autoimmune disease. No history of previous admission to the hospital or surgical history. No
history of regular drug using and no known drug allergy.
Family history:
There is similar conditions in the family, her sister have anemia. They have asthma as a familial
disease running in family. No history of Sickle cell, Thalassemia or infection in the family >
Obstetric history:
Regular menstruation. Heavy in flow. The last one was on 15 September, last for 11 days. The
intervals between each menstruation is 28 days.
Social history:
She is single, lives in Madinah. A student. She's a non-smoker or expose to it. She isn't on any
healthy diet nor do any exercises. Lives with her family, they have good socioeconomic state,
good water supply and sun exposure. No animal in the house. No travel history
Systemic review: was all negative.
General: No history of fever, decrease appetite, fatigability or weight loss.
Respiratory: No history of noisy breathing, no cough, no sputum, no hemoptysis.
CVs: no palpitations, no syncope, orthopnea or PND, no cyanosis.
GIT: No history of nausea, vomiting, abdominal pain, heartburn, or change in bowel habit.
CNS: no headache, no convulsions, no blurred vision or diplopia, no numbness and no change in
sensation.
MSs: no weakness and no joint or muscle pain.
GUs: No polyuria, hematuria, urgency, dysuria, oliguria, or change in urine color.no priapism.
Hematology & Skin: no epistaxis, no bruise, no lump, no itching, no rash, no hair/nail changes
Endocrine: no change in appetite or weight, sweating, polydipsia or polyuria.
ICE-E:
She was thinking that her symptoms are due to asthma since it runs in her family. She is afraid of
having asthma. The condition affects her life that she became so weak she could do her
schoolwork.
Physical examination: write down the finding of physical examination which help in patient
diagnosis and management
• General Examination:
The patient looking well, alert, cooperative, talking to me, oriented to time, place and person.
She is pale but not cyanosed. She is sitting comfortably on the chair, not in pain or in special
decubitus. She looks in underweight I should conform it by BMI.
• Vital signs:
- Pulse: 73beat/min, regular rhythm, symmetrical in both side, equal volume in both sides,
no special characters, no vessel wall abnormalities
- BP:125/83
- Respiratory rate: 16 breaths per minute
- Temperature: 37.3 C
• Hand/ Nails:
- Worm hand, pale, normal capillary refill, no clubbing, xanthomata, Leukonychia, koilonychias
or palmer erythema
• Face:
- there is a conjunctival pallor, but no jaundice, corneal arcus, xanthelasma, conjunctival
hemorrhage, no mallar flush, central cyanosis, angular stomatitis, Glossitis and normal mouth
hygiene.
• Neck:
- Visible carotid pulsation, palpable in both sides. No enlarged lymph node.
• chest examination:
- normal s1,s2 no murmurs .
• Abdominal examination:
- Abdomen is not distended, normal subcostal angle, no visible pulsation or peristalsis. No
scars, pigmentation, dilated veins, spider nevi. Umbilicus is centralized and inverted, no
discharge or caput medusa.
- The abdomen is soft, lax. No tenderness, masses. The liver, spleen and kidney were not
palpable.
- Abdomen is resonant, no area of dullness. liver span was normal (8 cm). Spleen is not
enlarged. No shifting dullness or fluid thrill.
- Audible bowel sounds with average intensity, No aortic or renal bruit.
- Rectal examination
• Neurological examination:
- Cranial nerve was intact, tone was normal, reflexes are intact, power 5/5, all type of sensation
was intact, normal cerebellar sign.
Red flags: in relation to the case need to be rolled out:
- Any bleeding
- Fainting or loss of consciousness
-confusion
- blurred vision or vision loss
-Cardiac symptoms.(chest pain, sever heart palpitations)
-fever
investigation : Investigation requested / interpretation of previous investigations
- Complete blood count (CBC)
- HBG: low
• Microcytosis (Low MCV)
• Hypochromic (Low MCH)
• Reticulocyte (Low number of reticulocytes)
• Red cell distribution width (High)
• Thrombocytosis
- Blood Peripheral Smear
• Anisocytosis = unequal size of RBCs
• Poikilocytosis = different size of RBCs
• Target cells
• Hypochromacia
- Special Tests:
• Low serum iron <60 ng/dl
• High total iron binding capacity (TIBC) >360 ng/dl
• Low serum ferritin (<12 ng/dl)
• High serum transferrin receptors (>8.5 mg/L)
• Bone marrow examination (not indicated)
Problems list:
- Headache
- Fatigability
- Tinnitus
- Palpitation
- Dyspnea
Management plan in steps:
1) Reassurance
Reassurance THE PATIENT That it’s very common and Explain underlying cause OF anemia is due to
iron deficiency . she need to start treatment .
2) Advice ( non-pharmacological )
- Eat and drink more:
dark-green leafy vegetables like watercress and curly kale
cereals and bread with extra iron in them (fortified)
meat
pulses (beans, peas and lentils)
Other foods that are a good source of iron.
Vit-c (drink orange juice)
- Eat and drink less:
Tea, coffee, milk and dairy
foods with high levels of phytic acid – such as wholegrain cereals, which can
stop your body absorbing iron from other foods and pills
Large amounts of these foods and drinks make it harder for your body to absorb
iron.
3) Prescribing drugs
- Diet—iron-rich foods, vitamin C rich foods (see TABLE 22.4). Iron is present in meat
+++ ++
and legumes as Fe and therefore requires gastric acid for conversion to Fe .
- Iron preparations:— oral iron (ferrous sulphate 1–2 tablets daily between meals for 6
months) e.g. Ferro- Gradumet with orange juice or ascorbic acid until Hb is normal
- parenteral iron preferably by IV infusion is probably best reserved for special
circumstances (there is a risk of an allergic reaction). Avoid blood transfusions if
possible.
4) Further investigation if needed
Hemoglobin electrophoresis (genetic anemia)
5) Referral / sick leave
No need
6) Observation &follow up
Follow up after 4 weeks of starting treatment to confirm the response.
7) Prevention
Continue treatment for 3 month after correction of iron deficiency to allow replenishment of the iron
stores.
Once normal monitor HB, MCH, MCV EVERY 3 MONTH FOR 1 YEAR.
