Response to Shannon

Please post a response on the post below.

 

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  • Review the patient case study and reflect on the information provided about the patient.
  • Think about the personal, medical, and family history you need to obtain from the patient in the case study. Reflect on what questions you might ask during an evaluation.
  • Consider types of physical exams and diagnostics that might be appropriate for evaluation of the patient in the study.
  • Reflect on a possible diagnosis for the patient.
  • Review the Marroquin article in this week’s Resources. If you suspect prostate cancer, consider whether or not you would recommend a biopsy.
  • Think about potential treatment options for the patient.

(Shannon’s Post)

Diagnosis of Case Study 3

            Case study 3 is a 52-year-old female presenting with a 6-week history of fatigue and weight loss. She has also noticed muscle cramping, tetany, and a tingling sensation around her mouth and lower extremities. She has a twenty-year history of Crohn’s disease, a type of inflammatory bowel disease (IBD). She also follows a vegan diet and reports intermittent, colicky abdominal pain. I must admit that this patient has me puzzled, due to her various complaints, along with her medical and dietary history. Despite this, my primary diagnosis is vitamin B-12 deficiency anemia.

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            Vitamin B-12 deficiency anemia may present with abdominal complaints, weight loss, fatigue, and neurologic symptoms, such as paresthesia from nerve damage (Green & Datta Mitra, 2017; Langan & Goodbred, 2017). Factors that predispose this patient to this form anemia include vegan diet and IBD (Green & Datta Mitra, 2017; Langan & Goodbred, 2017). Vegan diets often lack B-12, as it is primarily found in animal meat products (Green & Datta Mitra, 2017; Langan & Goodbred, 2017). Inflammatory bowel diseases often impair the gastrointestinal tract’s ability to absorb nutrients, especially vitamin B-12 (Green & Datta Mitra, 2017; Santarpia, Alfonsi, Castiglione, Pagano, Cioffi, Rispo, Sodo, Contaldo, Pasanisi, 2019). This is because B-12 is absorbed primarily in the terminal ileum, a common area impacted by Crohn’s disease (Green & Datta Mitra, 2017; Santarpia et al., 2019). However, many other nutrient deficiencies are common in IBD, such as folate, iron, vitamin D, magnesium, and calcium (Green & Datta Mitra, 2017; Krela-Ka?mierczak, Szymczak, ?ykowska-Szuber, Eder, Stawczyk-Eder, Klimczak, Krzysztof, & Horst-Sikorska, 2015; Santarpia et al., 2019). Based on the positive Chvostek’s sign, muscle tetany, and tingling sensations, this patient likely has hypocalcemia (Krela-Ka?mierczak et al., 2015). However, paresthesias can also occur with B-12 and magnesium deficiencies (Krela-Ka?mierczak et al., 2015). Furthermore, hypomagnesemia and hypovitaminosis D can contribute to hypocalcemia (Krela-Ka?mierczak et al., 2015).

 Differential Diagnoses

             My differential diagnoses for this patient include cancer, hyperparathyroidism with chronic kidney disease, and malnutrition. Of these, cancer is the most concerning. Unintentional weight loss is associated with up to forty percent of all cancer diagnoses (Vierboom, Preston, & Stokes, 2018). Given her twenty-year history of Crohn’s disease, she is at a significant risk of gastrointestinal cancer compared to the general population (Santarpia et al., 2019). Cancers in the gastrointestinal tract can have a vague presentation initially, including abdominal discomfort, fatigue, and various nutrient deficiencies (Santarpia et al., 2019).

            Secondary hyperparathyroidism with chronic kidney disease (CKD) is another possibility. Hyperparathyroidism with CKD will lead to hypocalcemia and may be seen concurrently with hypovitaminosis D and malabsorption disorders such as Crohn’s (Duque, Elias, & Myoses, 2020). The primary symptoms are often related to hypocalcemia (Duque  et al., 2020). Fatigue, weight loss, and abdominal complaints may be present, either from kidney disease, Crohn’s disease, or even low vitamin D levels (Duque  et al., 2020; Jhamb, Abdel-Kader, Yabes, Wang, Weisbrod, Unruh, & Steel, 2017).

             Malnutrition is another possibility in this patient. Inadequate nutritional intake or malabsorption from Crohn’s disease can prevent the absorption of vital nutrients, protein, calories, and fat, leading to general malnutrition (Adesogan, Havelaar, McKune, Elitta, & Dahl, 2020; Santarpia et al., 2019). Symptoms of malnutrition are varied, based on the specific deficiencies present (Adesogan et al., 2020).

History, Physical Exam, and Treatment

            This patient’s 6-week history of concerning symptoms indicate a substantial underlying problem. She should be questioned regarding what medications she takes for her Crohn’s disease, as while they provide control of the IBD, they can have detrimental side effects (Adesogan et al., 2020; Langan & Goodbred, 2017). Also, knowing if she has ever had any surgery for her Crohn’s, such as removal of part of the small intestine, is essential. Since dietary practices are essential in identifying nutrient deficiencies, sources of fatigue, and weight loss, assessing her intake is necessary (Adesogan et al., 2020; Langan & Goodbred, 2017). I would ask the patient more about her vegan diet, such as how long she has been vegan, what her typical intake consists of, and any vitamins and supplements she takes.

            The physical examination would include obtaining labs, such as a complete blood count with differential, comprehensive metabolic panel, and electrocardiogram (Langan & Goodbred, 2017). A parathyroid hormone, fasting serum phosphate, albumin, 25-hydroxyvitamin D, 1,25-dihydroxy vitamin D, and twenty-four-hour urine collection may assist in identifying parathyroid disorders (Langan & Goodbred, 2017). Renal ultrasound and abdominal computed tomography may also be indicated to assess kidney and bowel etiologies (Langan & Goodbred, 2017).

            Treatment of B-12 deficiency anemia includes adequate oral intake of B-12, B-12 supplementation, and appropriate management of co-morbid conditions contributing to deficiency (Langan & Goodbred, 2017). If patients cannot achieve adequate B-12 levels from oral administration, intramuscular injections may be necessary (Langan & Goodbred, 2017). Vegans with a severe deficiency that is resistant to treatment may need to consider dietary changes (Langan & Goodbred, 2017). Other vitamin and electrolyte abnormalities should also be addressed and managed (Langan & Goodbred, 2017).

 

Resources:

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

 

  • Part 13, “Evaluation and Management of Genitourinary Disorders” (pp. 731-798)
  • Part 17, “Evaluation and Management of Endocrine and Metabolic Disorders”

Adams, D., de Jonge, R., van der Cammen, T., Zietse, R., & Hoorn, E. J. (2011). Acute kidney injury in patients presenting with hyponatremia. Journal of Nephrology, 24(6), 749–755.

This article examines the correlation between acute kidney injury and hyponatremia. It also analyzes the effects of both disorders on patients.

Assadi, F. (2010). Hypomagnesemia: An evidence-based approach to clinical cases. Iranian Journal of Kidney Diseases, 4(1), 13–19.

This article explores the clinical presentation of and treatment options for hypomagnesemia. Patient case studies are also presented.

Marroquin, J. (2011). To screen or not to screen: Ongoing debate in the early detection of prostate cancer. Clinical Journal of Oncology Nursing, 15(1), 97–98.

This article analyzes the controversy surrounding prostate cancer screening. The strengths and limitations of prostate cancer screenings are also examined.

 

 

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