Common Hematologic Disorders in Primary Care

Common© Jones Hematologic & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC DisordersNOT FOR in SALE Primary OR DISTRIBUTION Care NOT FOR SALE OR DISTRIBUTION Karen S. Moore © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Case 1 - Anemia of Chronic Disease C. Pathophysiology D. Treatment Plan A. History and Physical Exam © Jones & Bartlett Learning, LLCE. Guidelines to Direct Care: © Jones & Bartlett Learning, LLC B. Recommended Labs/Diagnostics NOT FOR SALE OR DISTRIBUTION American Red Cross BloodNOT Donation FOR Guidelines. SALE OR DISTRIBUTION C. Pathophysiology National Institutes of Health. National Institute on Alcohol D. Treatment Plan Abuse and Alcoholism. Alcohol use disorder guideline. E. Guidelines to Direct Care: Kidney© Jones Disease: & BartlettImproving Learning,Global Outcomes LLC (KDIGO) Case 4© -Jones Iron Deficiency & Bartlett Anemia Learning, LLC Anemia Work Group. KDIGO clinical practice guideline for NOT FOR SALE OR DISTRIBUTION A. NOT FOR SALE OR DISTRIBUTION anemia in chronic kidney disease. History and Physical Exam B. KDIGO 2012 Clinical Practice Guideline for the Evaluation Recommended Labs/Diagnostics and Management of Chronic Kidney Disease. C. Pathophysiology D. Treatment Plan Case 2 - Anemia of B Deficiency © Jones & Bartlett Learning, LLC12 © JonesE. Guidelines & Bartlett to Direct Learning, Care: LLC NOT FORA. SALE History OR and DISTRIBUTIONPhysical Exam NOT FORTreatment SALE of AnemiaOR DISTRIBUTION in patients with heart disease: a clinical B. Recommended Labs/Diagnostics practice guideline from the American College of Physicians. C. Pathophysiology Case 5 - Alpha Thalassemia D. Treatment Plan © Jones & Bartlett Learning, LLCA. History and Physical Exam © Jones & Bartlett Learning, LLC Case 3 - AnemiaNOT of FolateFOR SALE Deficiency OR DISTRIBUTION B. Recommended Labs/DiagnosticsNOT FOR SALE OR DISTRIBUTION A. History and Physical Exam C. Pathophysiology B. Recommended Labs/Diagnostics D. Treatment Plan

9781284065800_CH05_063_084.indd 63 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 63 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 64 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Learning Objectives

Using a case-based approach, the learner will be able to: 3. State pathophysiology of common hematologic disorders. 4. 1. Identify key history and physical examination parameters for Document a clear, concise SOAP note for patients with com- © Jones & Bartlett Learning, LLCmon hematologic disorders.© Jones & Bartlett Learning, LLC common hematologicNOT disorders FOR seen SALE in primary OR care, DISTRIBUTION includ- NOT FOR SALE OR DISTRIBUTION ing anemia and thalassemia. 5. Identify relevant education and counseling strategies for pa- 2. Summarize recommended laboratory and diagnostic studies tients with common hematologic disorders. indicated for the evaluation of common hematologic disor- 6. Develop a treatment plan for common hematologic disorders ders seen in primary care. utilizing current evidence-based guidelines. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Case 1

Mr. Frederick is a 66-year-old African American male who pre- Skin: Dry skin with pruritus, no discoloration, no open areas © Jones &sents Bartlett with complaints Learning, of (c/o) LLC fatigue, increased shortness of© Jonesnoted & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION breath that worsens with walking or activity, and “just feeling Cardiovascular (CV): S1 and S2 regular rate and rhythm (RRR), bad.” Mr. Frederick has not been to a primary care provider in no murmurs, no rubs. 2+ edema noted to bilateral mid- “about 10 years.” States he went to the emergency room (ER) pretibial region of lower extremities “about a month ago” and was diagnosed with hypertension Lungs: Clear to auscultation (HTN) and kidney disease. States he was started on medica- Abdomen: Soft, nontender, nondistended, bowel sounds pres- tions to decrease fluid retention© Jones and treat & Bartlett his HTN and Learning, referred LLC © Jones & Bartlett Learning, LLC ent × 4 quadrants, no organomegaly, no bruits to your office for follow-up.NOT Unsure FOR of SALElast tetanus OR vaccination DISTRIBUTION NOT FOR SALE OR DISTRIBUTION date, does not get annual influenza vaccines. States he had “regu- Rectal: Normal vault, good tone, heme-negative stool lar childhood” immunizations. Denies significant illness prior to Neuro: Cranial nerves (CN) II–XII intact. Rhine/Weber nor- recent diagnoses. Denies chest pain, coughing, dizziness, vomit- mal, Romberg negative. Sensation intact, deep tendon re- ing. When queried further, Mr. Frederick reports some nausea flexes (DTR) 2+ © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and itching skin that has gotten progressively worse over the last What additional assessments do you need? few months.NOT FORDenies SALEsurgeries OR or prior DISTRIBUTION hospitalizations. Denies NOT FOR SALE OR DISTRIBUTION What is the differential diagnoses list? alcohol use, illicit drug use, tobacco use. No known drug allergies (NKDA). Current medications: furosemide 10 mg QD and What is your working diagnosis? lisinopril 5 mg QD. Additional Assessments/Diagnostics © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Physical Exam Needed NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Vital Signs: Blood pressure (BP) 168/94, heart rate (HR) 116, Mr. Frederick presents with symptoms of anemia and chronic kid- respiratory rate (RR) 20, temperature (T) 98.8, height (Ht) ney disease.1–8 Anemia is characterized by decreased hemoglobin 6'2", weight (Wt) 325 lbs and hematocrit identified on lab testing but may have multiple General (GEN): Progressive fatigue. Denies fever, chills, or causes requiring different interventions to correct underlying dis- night sweats. No acute© distressJones & Bartlett Learning, LLCease pathology. It is important to© identify Jones the underlying& Bartlett cause Learning, of LLC Head, eyes, ears, nose, andNOT throat FOR (HEENT): SALE Head OR normoceDISTRIBUTION- Mr. Frederick’s anemia. NOT FOR SALE OR DISTRIBUTION phalic without evidence of masses or trauma. Pupils equal, His diagnosis of HTN and his fluid retention dictate that a round, react to light, accommodation (PERRLA), extraocu- more careful evaluation be completed to evaluate for cardiovascular movements (EOMs) full to confrontation. Noninjected. lar disease. It is important to remember that HTN can be a com- Fundoscopic exam unremarkable with exception of pale reti- plication of kidney disease, or it may have been a causative factor. nal© background.Jones & PalpebralBartlett conjunctiva Learning, pale. LLCEar canal with- Because Mr. ©Frederick Jones has & not Bartlett been evaluated Learning, in 10 years, LLC it is dif- outNOT redness FOR or irritation, SALE tympanicOR DISTRIBUTION membranes (TMs) clear, ficult to determineNOT whetherFOR SALEhis HTN OR preceded DISTRIBUTION the kidney failure pearly, bony landmarks visible. No discharge, no pain noted. or the elevated blood pressure is a result of worsening kidney func- Pale nasal mucosa. Posterior pharynx pale. Neck: Supple tion. Regardless, evaluation of complications of HTN and kidney without masses. No thyromegaly. No jugular vein distention disease should be undertaken as well as identification of the cause (JVD) noted. of his anemia. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 64 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 64 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 1 65 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEEvaluation OR for patientsDISTRIBUTION with suspected anemia should include:NOT FORÑÑPre senceSALE or absence OR DISTRIBUTION of complications of anemia: ÑÑ ÑÑRisk factors for anemia: Arrhythmia ÑÑAnemia risk increases with age. Although the exact etiol- ÑÑCongestive heart failure ogy of anemia in elderly persons may be multifactorial, ÑÑEnd organ damage such as liver and kidney failure advancing age is a© known Jones risk factor& Bartlett for anemia. Learning, LLC © Jones & Bartlett Learning, LLC ÑÑ ROS A diet that is deficientNOT in FORquality SALEprotein sources OR DISTRIBUTION and B vi- NOT FOR SALE OR DISTRIBUTION tamins is a known risk factor for anemia. Hematopoiesis Focus additional questions on assessment of the impact that his requires healthy levels of macronutrients and micronutri- anemia symptoms are having on his activities of daily living as well ents to carry out cell production and maturation. as potential clues to the cause of his anemia, including: ÑÑIntestinal disorders such as malabsorptive disorders, para- ÑÑFatigue (Mr. Frederick reports fatigue) ©sitism, Jones lack of& intrinsic Bartlett factor, Learning, gastric bypass surgery,LLC Crohn’s ÑÑChest pain© (denies)Jones & Bartlett Learning, LLC disease, and ulcerative colitis increase the risk of anemia. NOT FOR SALE OR DISTRIBUTION ÑÑPalpitationsNOT (denies) FOR SALE OR DISTRIBUTION ÑÑChronic diseases such as thyroid, liver, kidney, or autoim- ÑÑShortness of breath (SOB) (Mr. Frederick reports SOB) mune diseases as well as HIV/AIDS and cancer increase Ñ the risk of anemia. Mr. Frederick has a recent diagnosis of ÑDyspnea on exertion (DOE) (Mr. Frederick reports DOE) chronic kidney disease, so you need to investigate whether ÑÑDizziness (denies) © Jones & Bartletthis kidney Learning, disease is the LLC cause of his anemia. © JonesÑÑHea &dache Bartlett (denies) Learning, LLC NOT FOR SALEÑÑPregnancy, OR DISTRIBUTION childbirth, and dysfunctional uterine bleedingNOT FORÑÑCoolne SALEss in hands OR andDISTRIBUTION feet or paresthesias (denies) predispose women to anemia. ÑÑNausea/vomiting—patients with chronic kidney disease of- ÑÑInherited diseases such as sickle cell disease or trait as ten report nausea (Mr. Frederick reports nausea) well as the thalassemias can interfere with production and ÑÑWorsening of these symptoms with activity can provide an maturation of red blood cells. © Jones & Bartlett Learning, LLCestimate of the severity of anemia© Jones & Bartlett Learning, LLC ÑÑBone marrow dysfunction such as myelodysplastic syndrome, blood or boneNOT cancers, FOR and SALE marrow OR suppression DISTRIBUTION by Further discussion of cardiovascularNOT riskFOR factors SALE should OR also DISTRIBUTIONbe medications, toxins, or disease increase the risk of anemia. explored, including: Ñ ÑÑIdentifiable causes of anemia: ÑHTN—Mr. Frederick has been diagnosed with HTN ÑÑBleeding: Either chronic or acute blood loss can be the cause ÑÑCigarette smoking—Mr. Frederick is a nonsmoker © ofJones anemia. In& the Bartlett case of Mr. Learning, Frederick, he deniesLLC any signs ÑÑObesity©—Mr. Jones Frederick & Bartletthas a body massLearning, index of 41.7 LLC NOTor symptoms FOR SALEof upper gastrointestinalOR DISTRIBUTION blood loss, he is male, ÑÑPhysicalNOT inactivity—Mr. FOR SALE Frederick OR does DISTRIBUTION not exercise which precludes menstrual abnormalities as the cause of his ÑÑDyslipidemia—you will need to order labs anemia, and his stool was negative for blood during exam, ÑÑDiabetes mellitus—you will need to order labs which lessens the likelihood that his anemia is related to Ñ lower gastrointestinal loss. Depending on his laboratory ÑMicroalbuminuria or estimated glomerular filtration rate (GFR)—you will need to order urine analysis and © Jones & Bartletttesting, Learning,this cause of anemia LLC may need to be explored in© Jones & Bartlett Learning, LLC addition to other more likely causes. labs. This will be in addition to other kidney-related NOT FOR SALE OR DISTRIBUTION NOT FORevaluations SALE OR DISTRIBUTION ÑÑDiminished red blood cell (RBC) production: For Mr. Fre derick, Ñ his diagnosis of kidney disease should increase suspicion of ÑAge—Mr. Frederick is 66 years old the potential cause of his anemia. Chronic kidney disease is ÑÑFamily history—when queried further, he reports his associated with a decreased level of erythropoietin, which mother and father both had HTN, diabetes mellitus (DM), is a hormone secreted© Jones by the kidneys & Bartlett that is necessary Learning, for LLCand chronic kidney disease (CKD).© Jones These & are Bartlett significant Learning,risk LLC RBC production. NOTThis probable FOR etiology SALE for OR Mr. Frederick’s DISTRIBUTION factors NOT FOR SALE OR DISTRIBUTION anemia should be further explored with laboratory testing. ÑÑRapid rates of red blood cell destruction: Inherited or acquired Physical Exam diseases that cause an increased rate of RBC destruction The physical examination for this patient should include: can lead to anemia. Mr. Frederick’s medical history does © notJones suggest & any Bartlett of these potential Learning, causes nor LLC does his physi- ÑÑA thorough© Jones assessment & ofBartlett the heart Learning,and lungs for signsLLC and NOTcal examination FOR SALE reveal ORenlargement DISTRIBUTION or abnormality of his symptomsNOT (s/s) FOR of card SALEiac complications OR DISTRIBUTION of anemia and kid- spleen. If suspected, laboratory studies to rule out sickle ney disease (arrhythmias, extracardiac sounds, murmurs or cell disease and thalassemia should be performed. If other rubs, auscultation of lungs) causes are ruled out, further studies for causative agents of ÑÑEvaluation for fluid overload (peripheral edema, JVD, card iac hemolytic anemia may be undertaken. and lung evaluation) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 65 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 65 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 66 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 2 NOT FOR ÑSALEÑAppropr ORiate DISTRIBUTIONmeasurement of blood pressure with verificaNOT- FORÑÑGlomerul SALEar filtration OR DISTRIBUTION rate (GFR) 40 (mL/min per 1.73 m )— tion in the contralateral arm GFR of 30–59 is considered Stage 3 CKD7 Ñ ÑPalpation of the lower extremities for edema and peripheral Additional anemia studies: pulses Ñ ÑÑExamination of the abdomen for enlarged spleen, liver, ÑSerum iron (low) changes in kidneys ©(either Jones enlarged & Bartlettor smaller thanLearning, antici- LLCÑÑSerum ferritin (low) © Jones & Bartlett Learning, LLC pated), masses, and abnormalNOT FOR aortic SALE pulsations OR DISTRIBUTIONÑÑTotal iron-binding capacity NOT(TIBC) FOR (low) SALE OR DISTRIBUTION

ÑÑExamination of the skin and nails for complications of anemia ÑÑVitamin B12 (may be abnormal in some anemias, but in the and kidney disease (pruritus, spoon nails [koilonychias]) case of Mr. Frederick it is normal) ÑÑExamination of the mucous membranes for s/s of anemia ÑÑFolate (may be abnormal in some anemias, but in the case of (pallor,© Jones glossitis & of Bartlett the tongue, Learning, angular cheilitis LLC of the mouth) Mr. Frederick© Jones it is normal) & Bartlett Learning, LLC ÑÑReticulocyte count (low) RoutineNOT FOR Labs SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ÑÑRed cell distribution width (RDW) (variable but within nor- Routine labs for Mr. Frederick should include those directed at mal range) assessing his kidney function as well as his anemia and end organ ÑÑPeripheral blood smear (poikilocytosis) function. Additional labs: © Jones &Baseline Bartlett studies: Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORÑ Liver SALE function ORtests: DoneDISTRIBUTION as baseline study related to possible Ñ Ñ ÑComprehensive metabolic panel, including: causes of anemia and potential for cholesterol management ÑÑ Albumin (normal) (normal) ÑÑ Alkaline phosphatase (normal) ÑÑCholesterol panel: Advised to assess for cardiovascular disease ÑÑALT (alanine aminotransferase) (normal) © Jones & Bartlett Learning, LLC(CVD). Done as baseline study© Jones related to & Mr. Bartlett Frederick’s Learning, age LLC ÑÑAST (aspartate aminotransferase) (normal) and years since last primary care evaluation (Mr. Frederick’s NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ÑÑBlood urea nitrogen (BUN) (elevated) cholesterol and low-density lipoprotein [LDL]/high-density ÑÑCreatinine (elevated) lipoprotein [HDL] ratio results suggest the need for further intervention) ÑÑCalcium (normal) ÑÑThyroid studies: If thyroid disease is suspected (not done for ÑÑChloride (normal) Mr. Frederick) Ñ©Ñ CarbonJones dioxide & Bartlett (normal) Learning, LLC © Jones & Bartlett Learning, LLC Ñ Erythropoietin (EPO) studies may be ordered to ÑNOTÑ FOR SALE OR DISTRIBUTION ÑEPO: NOT FOR SALE OR DISTRIBUTION Glucose (normal) determine whether CKD and resultant erythropoietin defi- ÑÑ Potassium (high normal range) ciency is the cause of anemia (Mr. Frederick’s EPO is low) ÑÑSodium (normal) Potential diagnostic studies: ÑÑTotal bilirubin (normal) © Jones & BartlettÑÑTotal protein Learning, (normal) LLC © JonesÑÑRen &al Bartlett ultrasound—to Learning, determine LLC size, shape, and density of kidneys NOT FOR ÑSALEÑComple ORte blood DISTRIBUTION count, including: NOT FOR SALE OR DISTRIBUTION Ñ ÑÑRBC (low) Ñ Renal biopsy—to determine precise etiology of kidney disease ÑÑHemoglobin (Hgb) 11% (low) Differential Diagnoses List ÑÑHematocrit (Hct) 33% (low) Chronic kidney disease ÑÑMCV mean corpuscular volume (normal) © Jones & Bartlett Learning, LLCAnemia of chronic disease © Jones & Bartlett Learning, LLC ÑÑMCH mean corpuscular hemoglobin (normal) NOT FOR SALE OR DISTRIBUTIONAnemia of B12 deficiency NOT FOR SALE OR DISTRIBUTION ÑÑMCHC mean corpuscular hemoglobin concentration Anemia of folate deficiency (normal) Hypertension ÑÑPlatelets (normal) ÑÑ Cardiovascular disease © WhiteJones blood & cellsBartlett (WBCs) Learning, (basophils, eosinophils, LLC lym- © Jones & Bartlett Learning, LLC phocytes, monocytes, neutrophils) (normal) Congestive heart failure NOT FOR SALE OR DISTRIBUTION Diabetes mellitusNOT FOR SALE OR DISTRIBUTION Additional kidney function studies: Obesity Ñ ÑUrinalysis (UA) (protein ++) Working Diagnoses ÑÑ24-hour urine (A 24-hour urine is completed to assess for © Jones & Bartlettsedimentation Learning, and creatinine LLC clearance to provide informa©- JonesChronic & Bartlett kidney disease—Stage Learning, 3 LLC NOT FOR SALEtion on OR kidney DISTRIBUTION function) NOT FORAnemia SALE of chronic OR disease DISTRIBUTION

9781284065800_CH05_063_084.indd 66 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 66 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 1 67 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEHypertension OR DISTRIBUTION NOT FORÑÑLife styleSALE modifications OR DISTRIBUTION to decrease CVD risk Obesity ÑÑDietary modifications for weight loss, chronic kidney dis- Pathophysiology ease, CVD ÑÑIncrease activity Anemia is defined as a hemoglobin level of less than 12.0 mg/ 1–8 ÑÑDietary consultation dL in adult females and less© Jones than 13.5 & mg/dL Bartlett in adult Learning, males. LLC © Jones & Bartlett Learning, LLC Ñ Anemia is the most commonNOT blood FOR disorder SALE in the OR United DISTRIBUTION States ÑElectrocardiogram (ECG) inNOT office FOR SALE OR DISTRIBUTION and affects nearly 3 million persons annually. Anemia of chronic ÑÑConsider cardiology consultation for further evaluation of disease (ACD), as in the case of chronic kidney disease, is caused CVD with exercise tolerance test (ETT) primarily by decreased erythropoietin leading to a decreased reticulocyte count. ACD is diagnosed by careful observation of Education/Counseling the lab© values. Jones ACD & is Bartlett referred to Learning,as a normocytic, LLC normochro- © Jones & Bartlett Learning, LLC Ñ mic anemia.NOT ThisFOR means SALE that ORthe MCV DISTRIBUTION is normal, and MCHC ÑLifestyleNOT modifications FOR SALE OR DISTRIBUTION is normal. The reticulocyte count is low, with variability in the ÑÑDietary modifications size of the RBCs, but the RDW is still within normal limits. The ÑÑSodium restriction RBCs may demonstrate abnormal shapes on the smear, known ÑÑWeight loss as poikilocytosis. The serum iron and TIBC will be low. ÑÑDietary consultation © Jones & AlthoughBartlett other Learning, forms of anemia LLC may also be present and co©- Jones & Bartlett Learning, LLC Ñ Signs and symptoms of worsening anemia/CKD NOT FORexist SALE in a patientOR DISTRIBUTION with chronic kidney disease or other chronicNOT FORÑ SALE OR DISTRIBUTION illnesses, Mr. Frederick’s lab results suggest an anemia caused by ÑÑLiving well with CKD erythropoietin insufficiency leading to lowered RBC production by the bone marrow. SOAP Note What Is Your Treatment© Jones Plan?& Bartlett Learning, LLCS: Mr. Frederick is a 66-year-old© Jones African American & Bartlett male whoLearning, LLC NOT FOR SALE OR DISTRIBUTIONpresents with c/o fatigue, DOE,NOT and FOR malaise SALE as well OR as nau DISTRIBUTION- Pharmacologic sea and itching. Mr. Frederick has not been to a primary care provider in “about 10 years.” Mr. Frederick was diag- Continue Mr. Frederick on his current dosage of furosemide and nosed with HTN and renal disease at the emergency room 1–8 lisinopril. This medication regimen may need to be adjusted one month ago, started on medications for treatment, and once ©evaluated Jones by &a renal Bartlett specialist, Learning, but at the current LLC dosage it referred© for Jones primary &care Bartlett follow-up. Learning, Unsure of last LLC tetanus shouldNOT be well FOR tolerated SALE by Mr. OR Frederick. DISTRIBUTION Remember that anemia vaccinationNOT date, FOR does SALE not get ORannual DISTRIBUTION influenza vaccines. is treated by identifying the root cause and then treating that dis- States he had “regular childhood” immunizations. Denies ease process. In the case of chronic kidney disease, erythropoietin significant illness prior to recent diagnoses. Denies chest deficiency is the cause of the anemia so that is where you should pain, coughing, dizziness, vomiting. Denies surgeries or focus your treatment. Erythropoietin-stimulating agents (ESAs) prior hospitalizations. Denies alcohol use, illicit drug use, © Jones &are Bartlettgiven via injection Learning, and could LLC be a consideration for Mr. Fred©- Jonestobacco & Bartlett use. NKDA. Learning, Current LLCmedications: furosemide erick. ESAs should be initiated and managed by the renal specialist NOT FOR SALE OR DISTRIBUTION NOT FOR10 mg SALE QD and OR lisinopril DISTRIBUTION 5 mg QD. because this medication is not without risk. Mr. Frederick’s Hgb is O: Vital Signs: BP 168/94, P 116, RR 20, T 98.8, Ht 6'2", Wt 11%, which is the target Hgb for persons with chronic kidney dis- 325 lbs ease. For that reason, it is unlikely that ESAs would be initiated. Iron GEN: Progressive fatigue. Denies fever, chills, or night sweats. supplementation will generally be initiated whether or not ESAs No acute distress are included in Mr. Frederick’s© Jones treatment & plan. Bartlett Oral iron Learning,may not be LLC © Jones & Bartlett Learning, LLC effective in patients with CKD related to decreased absorption of HEENT: Head normocephalic without evidence of masses or iron from the gastrointestinalNOT (GI) FOR tract. Intravenous SALE OR (IV) DISTRIBUTION iron may trauma. PERRLA, EOMs fullNOT to confrontation. FOR SALE Noninjected. OR DISTRIBUTION be an acceptable alternative if iron stores do not improve with oral Fundoscopic exam unremarkable with exception of pale reti- iron dosing regimens but should be managed by the renal specialist. nal background. Palpebral conjunctiva pale. Ear canal without redness or irritation, TM clear, pearly, bony landmarks Nonpharmacologic visible. No discharge, no pain noted. Pale nasal mucosa. Pos- © Jones & Bartlett Learning, LLC terior pharynx© Jones pale. Neck& Bartlett supple without Learning, masses. No LLC thyro- ÑÑReferNOTral FORto a renal SALE specialist. OR DISTRIBUTION megaly. NOTNo JVD FOR noted SALE OR DISTRIBUTION ÑÑConsider RBC transfusion if Hgb is below target based upon Skin: Dry skin with pruritus, no discoloration, no open areas patient’s s/s and comorbid conditions. This is not indicated noted in Mr. Frederick CV: S1 and S2 RRR, no murmurs, no rubs. 2+ edema noted to Ñ © Jones & BartlettÑRenal ultrasound—to Learning, be orderedLLC by renal specialist © Jonesbilateral & Bartlett mid-pretibial Learning, region of lower LLC extremities Ñ NOT FOR SALEÑRenal biopsy—toOR DISTRIBUTION be ordered by renal specialist NOT FORLungs: SALEClear to auscultationOR DISTRIBUTION

9781284065800_CH05_063_084.indd 67 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 67 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 68 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEAbdomen: OR Soft, DISTRIBUTION nontender, nondistended, bowel sounds presNOT- FORGuidelines SALE OR to DISTRIBUTIONDirect Care ent × 4 quadrants, no organomegaly, no bruits Centers for Disease Control and Prevention. Recommended Rectal: Normal vault, good tone, heme-negative stool adult immunization schedule, by vaccine and age group. Neuro: CN II–XII intact. Rhine/Weber normal, Romberg nega- 2015. http://www.cdc.gov/vaccines/schedules/hcp/imz/ tive. Sensation intact, DTR 2+. © Jones & Bartlett Learning, LLCadult.html. Accessed September© Jones 16, 2015. & Bartlett Learning, LLC Lab Results: RBC, Hgb, Hct, retic, serum Fe, TIBC decreased, NOT FOR SALE OR DISTRIBUTIONKidney Disease: ImprovingNOT Global FOR Outcomes SALE (KDIGO) OR DISTRIBUTION RDW, MCV, MCHC normal Anemia Work Group. KDIGO clinical practice guideline for A: Chronic kidney disease—Stage 3 anemia in chronic kidney disease. Kidney Int Suppl. 2012; Anemia of chronic disease 2(4):279–335. http://www.kdigo.org/clinical_practice_ Hypertension guidelines/pdf/KDIGO-Anemia%20GL.pdf. Accessed Sep- Obesity© Jones & Bartlett Learning, LLC tember 16,© 2015.Jones & Bartlett Learning, LLC P: ReferNOT to FORrenal specialist SALE for OR further DISTRIBUTION evaluation and manage- Kidney Disease:NOT Improving FOR SALE Global OROutcomes DISTRIBUTION (KDIGO) Ane- ment of renal disease and recommendations for anemia of mia Work Group. KDIGO 2012 clinical practice guideline chronic disease. Recommend lifestyle and dietary modifi- for the evaluation and management of chronic kidney dis- cations for renal, CVD, and weight loss. Refer to dietitian. ease. Kidney Int Suppl. 2013(3):1. http://www.kdigo.org/ Continue lisinopril and furosemide. Vaccinations recom- clinical_practice_guidelines/pdf/CKD/KDIGO_2012_ © Jones & Bartlettmended: hepatitisLearning, A, hepatitis LLC B, pneumonia, shingles, and© JonesCKD_GL.pdf. & Bartlett Accessed Learning, September LLC 16, 2015. NOT FOR SALEannual OR influenza. DISTRIBUTION Schedule colonoscopy. Follow-up in NOT2 FORUS Preventive SALE Services OR DISTRIBUTION Task Force. Published recommendations. weeks to assess medication tolerance, verify referral ap- http://www.uspreventiveservicestaskforce.org/BrowseRec/ pointments, and review plan of care. Index/browse-recommendations. Accessed September 16, 2015. Health Promotion Issues7–8 World Health Organization. Haemogolobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin ÑÑVaccinations: Hepatitis© JonesA, hepatitis & B,Bartlett pneumonia, Learning, shingles, LLCand Mineral Nutrition Information© Jones System. & Bartlett Geneva: World Learning, LLC annual influenza NOT FOR SALE OR DISTRIBUTIONHealth Organization; 2011.NOT http://www.who.int/vmnis/ FOR SALE OR DISTRIBUTION ÑÑSchedule colonoscopy indicators/haemoglobin.pdf. Accessed September 16, 2015.

Mrs. Williams is a 68-year-old white female who presents with GEN: Progressive fatigue that is causing her to cut down on her a complaint of fatigue that has gradually worsened over the last normal activities. Denies fever, chills, or night sweats. No 6 months. The fatigue is not associated with chest pain, SOB, dia- acute distress © Jones &phoresis, Bartlett or palpitations. Learning, She also LLC recently noticed coldness as well© JonesHEENT: & Bartlett Head normocephalic Learning, without LLC evidence of masses or NOT FORas SALE numbness OR and DISTRIBUTIONtingling in her lower extremities and intermittenNOTt FORtrauma. SALE PERRLA, OR EOMsDISTRIBUTION full to confrontation. Noninjected. dizziness when moving quickly from a seated to a standing position. Fundoscopic exam unremarkable with exception of pale reti- Denies changes in bowel/bladder habits, denies appetite changes. nal background. Palpebral conjunctiva pale. Ear canal with- Past medical history (PMH) of measles, mumps, rubella, and chick- out redness or irritation, TM clear, pearly, bony landmarks enpox in childhood. Denies significant medical conditions. Uses visible. No discharge, no pain noted. Pale nasal mucosa. occasional ibuprofen as needed© Jones for arthralgia. & Bartlett No surgeries Learning, or hos- LLCPosterior pharynx pale with© beefy Jones red tongue. & Bartlett Neck: Supple Learning, LLC pitalization. NKDA. ReportsNOT immunizations FOR SALE up-to-date, OR DISTRIBUTION tetanus without masses. No thyromegaly.NOT No FOR JVD SALE OR DISTRIBUTION booster vaccination 3 years ago, shingles and pneumonia vaccina- CV: S1 and S2 RRR, no murmurs, no gallops, no rubs tion 2 years ago, influenza vaccination annually. Mrs. Williams’s last Lungs: Clear to auscultation mammogram and well-woman exam were 3 years ago, and both were normal. Natural menopause and last menstrual period 15 years ago. Abdomen: Soft, nontender, nondistended, bowel sounds pres- Denies© tobacco Jones use, & alcohol Bartlett consumption, Learning, illicit drug LLC use. ent × 4 quadrants,© Jones no & organomegaly, Bartlett Learning,no bruits LLC NOT FOR SALE OR DISTRIBUTION Back: NontenderNOT toFOR palpation. SALE No painOR with DISTRIBUTION forward flexion of Physical Exam low back but reports some mild dizziness with touching toes. Vital Signs: BP 126/80 supine, 118/76 sitting, 110/68 standing No costovertebral angle (CVA) tenderness with reported mild dizziness, HR 82 regular, RR 14, T 98.7, GU: Normal pelvic exam Ht 5'5", Wt 135 lbs Rectal: Normal vault, good tone, heme-negative stool © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 68 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 68 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 2 69 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALENeuro: CN OR II–XII DISTRIBUTION intact. Rhine/Weber normal, Romberg posiNOT- FORÑÑIden SALEtifiable causes OR ofDISTRIBUTION anemia: tive. Some difficulty with tandem walking. Paresthesias noted ÑÑBleeding: Either chronic or acute blood loss can be the with monofilament testing of bilateral feet, DTR 1+ cause of anemia. In the case of Mrs. Williams, she denies What additional assessments/diagnostics do you need? any signs or symptoms of upper gastrointestinal blood loss, she denies any postmenopausal bleeding, and her What is the differential diagnoses list? © Jones & Bartlett Learning, LLC stool was negative for blood© Jones during exam,& Bartlett which lessens Learning, LLC What is your workingNOT diagnosis? FOR SALE OR DISTRIBUTIONthe likelihood that her anemiaNOT isFOR related SALE to lower OR gastro DISTRIBUTION- intestinal loss. Depending on her laboratory testing, this Additional Assessments/Diagnostics cause of anemia may need to be explored in addition to Needed other more likely causes. ÑÑDiminished red blood cell (RBC) production: Laboratory Mrs. Williams© Jones presents & Bartlett with symptoms Learning, of anemia LLC that are sus- © Jones & Bartlett Learning, LLC 1–4,7–10 testing will determine whether a vitamin deficiency is the piciousNOT for a FOR vitamin-deficient SALE OR cause. DISTRIBUTION Further explora- NOT FOR SALE OR DISTRIBUTION tion of her medical history, including family history, as well cause for Mrs. Williams’s diminished blood counts. as laboratory and diagnostic studies will be important to help ÑÑRapid rates of red blood cell destruction: Inherited or ac- narrow the potential cause. Her symptoms of coolness, numb- quired diseases that cause an increased rate of RBC de- ness, and tingling in her extremities as well as dizziness and struction can lead to anemia. Mrs. Williams’s medical © Jones &swelling Bartlett of her Learning, tongue need toLLC be evaluated further to deter©- Jones &history Bartlett does notLearning, suggest any LLC of these potential causes nor does her physical examination reveal enlargement or NOT FORmine SALE whether OR these DISTRIBUTION could be attributed to her anemia or anNOT- FOR SALE OR DISTRIBUTION other cause. abnormality of the spleen. If other causes are ruled out, Evaluation for Mrs. Williams’s suspected anemia should further studies for causative agents of hemolytic anemia include: may be undertaken. ÑÑPresence or absence of complications of anemia: ÑÑRisk factors for anemia: © Jones & Bartlett Learning, LLCÑÑArrhythmia © Jones & Bartlett Learning, LLC ÑÑAnemia risk increases with age. Although the exact etiol- ÑÑ ogy of anemia inNOT elderly FOR persons SALE may be OR multifactorial, DISTRIBUTION Congestive heart failureNOT FOR SALE OR DISTRIBUTION advancing age is a known risk factor for anemia. ÑÑEnd organ damage such as liver and kidney failure ÑÑA diet that is deficient in quality protein sources and B vitamins is a known risk factor for anemia. Because you sus- ROS © pectJones a vitamin-deficient & Bartlett cause Learning, in the case of LLC Mrs. Williams, © Jones & Bartlett Learning, LLC a careful dietary assessment should be conducted. Focus additional questions on assessment of the impact that her NOT FOR SALE OR DISTRIBUTION anemia symptomsNOT are FOR having SALE on her OR activities DISTRIBUTION of daily living as ÑÑIntestinal disorders such as malabsorptive disorders, well as potential clues to the cause of her anemia, including: parasitism, lack of intrinsic factor, gastric bypass surgery, Crohn’s disease, and ulcerative colitis increase the risk of ÑÑFatigue (Mrs. Williams reports fatigue) anemia. Mrs. Williams denies a personal history of intes- ÑÑChest pain (denies) © Jones & Bartletttinal disorders Learning, but does LLC report a family history of perni©- JonesÑÑPalpit & Bartlettations (denies) Learning, LLC cious anemia in her mother. NOT FOR SALE OR DISTRIBUTION NOT FORÑÑShortne SALEss of breathOR DISTRIBUTION (SOB) (denies) ÑÑChronic diseases such as thyroid, liver, kidney, or autoim- ÑÑDyspnea on exertion (DOE) (denies) mune diseases as well as HIV/AIDS and cancer increase Ñ Dizziness (Mrs. Williams reports dizziness) the risk of anemia. Mrs. Williams denies personal history Ñ of chronic disease, reports history of autoimmune disor- ÑÑHeadache (denies) der in her mother.© Jones & Bartlett Learning, LLCÑÑCoolness in hands and feet© or Jones paresthesias & Bartlett(Mrs. Williams Learning, LLC ÑÑPregnancy, childbirth,NOT and FOR dysfunctional SALE uterine OR DISTRIBUTION bleeding reports this symptom) NOT FOR SALE OR DISTRIBUTION predispose women to anemia. Mrs. Williams is postmeno- ÑÑWorsening of these symptoms with activity can provide an pausal and denies any abnormal bleeding. estimate of the severity of the anemia (Mrs. Williams reports ÑÑInherited diseases such as sickle cell disease or trait as worsening with activity) well as the thalassemias can interfere with production and © Jones & Bartlett Learning, LLC Explore her© health Jones history & further,Bartlett making Learning, note of hints LLC to what maturation of red blood cells. Mrs. Williams has no his- the vitamin deficiency may be: NOTtory ofFOR inherited SALE blood OR disorders. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ñ ÑÑBone marrow dysfunction such as myelodysplastic syn- ÑAlcohol (ETOH) use (denies) drome, blood or bone cancers, and marrow suppression ÑÑMedications that may interfere with absorption such as hor- by medications, toxins, or disease increase the risk of mones, anticonvulsants, antineoplastic agents (denies) anemia. Mrs. Williams denies history of these diseases. Ñ Diet recall (vegetarian, low intake of B vitamins) © Jones & Bartlett Learning, LLC © JonesÑ & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 69 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 69 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 70 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR ÑSALEÑAddition ORal risk DISTRIBUTION factors: Women of northern European ancesNOT- FORÑÑ MCHCSALE (normal) OR DISTRIBUTION try who are prematurely gray with blue eyes, living in a north- ÑÑPlatelets (low) ern cold climate, have an increased risk of pernicious anemia ÑÑWBCs (basophils, eosinophils, lymphocytes, monocytes, neutrophils) (low) Physical Exam ÑÑUrinalysis (normal) The physical examination© for Jones this patient & shouldBartlett include: Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONAdditional anemia studies: NOT FOR SALE OR DISTRIBUTION ÑÑA thorough assessment of the heart and lungs for s/s of cardiac complications of anemia (arrhythmias, extracardiac ÑÑSerum iron (normal) sounds, murmurs or rubs, auscultation of lungs) ÑÑSerum ferritin (normal) ÑÑEvaluation for fluid overload (peripheral edema, JVD, car- ÑÑTotal iron-binding capacity (TIBC) (normal) diac© Jonesand lung evaluation)& Bartlett Learning, LLC ÑÑB12 (low)© Jones & Bartlett Learning, LLC ÑÑApproprNOT FORiate measurement SALE OR of blood DISTRIBUTION pressure with verification ÑÑFolate (normal)NOT FOR SALE OR DISTRIBUTION in the contralateral arm and in various positions (orthostatic) ÑÑReticulocyte count (normal) Ñ ÑPalpation of the lower extremities for edema and peripheral ÑÑRDW (elevated) pulses ÑÑPeripheral blood smear (macrocytosis, hyperpigmented neu- Ñ © Jones & BartlettÑExamination Learning, of the abdomen LLC for enlarged spleen, liver,© Jonestrophils, & Bartlett and giant Learning, platelets) LLC changes in kidneys, masses, and abnormal aortic pulsations NOT FOR SALE OR DISTRIBUTION NOT FORÑÑSchil SALEling’s test OR (positive) DISTRIBUTION ÑÑExamination of the skin and nails for complications of anemia (spoon nails [koilonychias]) Additional Labs and Diagnostic Testing Ñ ÑExamination of the mucous membranes for s/s of anemia ÑÑLiver function tests: Done as baseline study related to possible (pallor, glossitis of the tongue, angular cheilitis of the mouth) causes of anemia and potential for cholesterol management. © Jones & Bartlett Learning, LLCLactate dehydrogenase (LDH)© Jones is elevated. & Bartlett Learning, LLC Routine Labs NOT FOR SALE OR DISTRIBUTIONÑÑCholesterol panel: Advised toNOT assess forFOR CVD. SALE Done as ORbaseline DISTRIBUTION Routine labs for Mrs. Williams should include those directed at study related to Mrs. Williams’s age and years since last primary assessing her anemia. care evaluation. Mrs. Williams’s cholesterol panel is normal. Baseline studies: ÑÑThyroid studies: If thyroid disease is suspected. This was completed and was normal for Mrs. Williams. ÑÑCompre© Joneshensive & metabolic Bartlett panel, Learning, including: LLC © Jones & Bartlett Learning, LLC ÑÑEPO: Erythropoietin studies may be ordered to determine ÑNOTÑ FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Albumin (normal) whether erythropoietin deficiency is the cause of anemia. ÑÑAlkaline phosphatase (normal) Not done in this case. ÑÑALT (alanine aminotransferase) (elevated) ÑÑKOH test: Potassium hydroxide (KOH) test on scraping from ÑÑAST (aspartate aminotransferase) (normal) tongue to determine whether fungal infection is responsible © Jones & BartlettÑÑBUN (normal) Learning, LLC © Jonesfor & the Bartlett glossitis observedLearning, on Mrs. LLC Williams’s examination. NOT FOR SALEÑÑCreatinine OR DISTRIBUTION (normal) NOT FORThe SALE test was negativeOR DISTRIBUTION for fungal infection. Ñ ÑÑCalcium (normal) ÑSchilling’s test: The Schilling’s test is helpful in differentiating vitamin B –deficiency anemia from folic acid–deficiency ÑÑChloride (normal) 12 anemia. Mrs. Williams’s Schilling’s test is positive, which is ÑÑCarbon dioxide (normal) diagnostic for vitamin B12 deficiency. ÑÑGlucose (normal)© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Potential Diagnostic Studies ÑÑPotassium (normal)NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ÑÑSodium (normal) ÑÑColonoscopy for wellness and to rule out (r/o) occult GI bleed ÑÑTotal bilirubin (normal) ÑÑTotal protein (normal) Differential Diagnoses Ñ ÑComple© Joneste blood & count,Bartlett including: Learning, LLC Anemia of© vitamin Jones B12 deficiency & Bartlett Learning, LLC ÑNOTÑRBC FOR (low) SALE OR DISTRIBUTION Anemia ofNOT folate deficiency FOR SALE OR DISTRIBUTION ÑÑHgb (low) Iron-deficiency anemia—related to (r/t) malignancy, GI blood loss ÑÑHct (low) Postural hypotension ÑÑ MCV (elevated) Glossitis—can be r/t B12 or folate deficiency ÑÑ © Jones & BartlettMCH (normal)Learning, LLC © JonesPeripheral & Bartlett vascular diseaseLearning, (PVD) LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 70 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 70 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 2 71 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEWorking OR DISTRIBUTIONDiagnosis NOT FOREducation/Counseling SALE OR DISTRIBUTION Ñ Hypoproliferative macrocytic anemia secondary to vitamin B12 ÑReview diet with Mrs. Williams to identify areas of concern. deficiency ÑÑSchedule a formal dietary consultation to educate Mrs.

Peripheral neuropathy related to vitamin B12 deficiency Williams about ways to increase foods rich in vitamin B12. Ñ Leukopenia secondary ©to vitaminJones B 12& deficiency Bartlett Learning, LLCÑEncourage this patient to ©increase Jones her &fluids. Bartlett This should Learning, LLC help with the orthostatic hypotension she is experiencing. Thrombocytopenia secondaryNOT FOR to vitamin SALE B12 deficiency OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Elevated LDH and ALT secondary to vitamin B12 deficiency SOAP Note Glossitis due to vitamin B12 deficiency S: Mrs. Williams is a 68-year-old postmenopausal white female who presents with a complaint of fatigue, dizziness with Pathophysiology © Jones & Bartlett Learning, LLC position© changes, Jones and & coolness Bartlett and Learning,numbness in extremiLLC - Vitamin B12 deficiency leads to decreased production of RBC and ties that has gradually worsened over the last 6 months. She NOT FOR9 SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION resultant anemia. This deficiency can be caused by a lack of intrin- denies chest pain, SOB, diaphoresis, or palpitations, changes sic factor and is commonly known as pernicious anemia. Pernicious in bowel/bladder habits, appetite changes. PMH of measles, anemia occurs when cells in the stomach that synthesize intrinsic mumps, rubella, and chickenpox in childhood. Uses occasional factor are damaged by disease or surgical disruption, as with gas- ibuprofen as needed for arthralgia. NKDA. She reports her © Jones &tric Bartlett bypass. Pernicious Learning, anemia occursLLC more often in women than in© Jonesimmuniza & Bartletttions are Learning, up-to-date. Mrs. LLC Williams’s last mammo- NOT FORmen, SALE especially OR those DISTRIBUTION of northern European descent with fair skinNOT FORgram SALE and well-woman OR DISTRIBUTION exam were 3 years ago, and both were and blue eyes who reside in cool northern regions. Another cause normal. No tobacco use, alcohol consumption, illicit drug use. of vitamin B12 deficiency is damage to the intestine leading to an O: Vital Signs: BP 126/80 supine, 118/76 sitting, 110/68 inability of the GI track to absorb vitamin B12. This occurs in dis- standing with reported mild dizziness, HR 82 regular, RR 14, ease processes such as celiac disease, Crohn’s disease, or parasitism. T 98.7, Ht 5'5", Wt 135 lbs Vitamin B deficiency may occur simultaneously with other forms 12 © Jones & Bartlett Learning, LLCGEN: Progressive fatigue that is causing© Jones her to cut& downBartlett on her Learning,nor- LLC of anemia such as folate-deficiency and iron-deficiency anemia. NOT FOR SALE OR DISTRIBUTIONmal activities. Denies fever, chills,NOT or night FOR sweats. SALE No acute OR distress DISTRIBUTION What Is Your Treatment Plan? HEENT: Head normocephalic without evidence of masses or trauma. PERRLA, EOMs full to confrontation. Noninjected. Mrs. Williams is not acutely ill and has had progressive generalized Fundoscopic exam unremarkable with exception of pale reti- fatigue for 6 months.9 Her lab work clearly demonstrates vitamin nal background. Palpebral conjunctiva pale. Ear canal with- B deficiency, and she is complaining of neurologic problems 12 © Jones & Bartlett Learning, LLC out redness© Jones or irritation, & Bartlett TM clear, Learning,pearly, bony landmarks LLC (coolness in extremities, gait disorder, dizziness) consistent with NOT FOR SALE OR DISTRIBUTION visible. NoNOT discharge, FOR no SALE pain noted. OR Pale DISTRIBUTION nasal mucosa. Pos- her vitamin B –deficiency anemia. 12 terior pharynx pale with beefy red tongue. Neck supple with- Her BP is stable, but she does have BP changes with position. out masses. No thyromegaly. No JVD She is not tachycardic, not febrile, and not actively bleeding. She needs treatment for her vitamin deficiency and a colonoscopy CV: S1 and S2 RRR, no murmurs, no gallops, no rubs © Jones &screening Bartlett to rule Learning, out any GI bloodLLC loss and as a general health© JonesLungs: & Clear Bartlett to auscultation Learning, LLC NOT FORmaintenance SALE OR recommendation. DISTRIBUTION NOT FORAbdomen: SALE Soft, nontender,OR DISTRIBUTION nondistended, bowel sounds present × 4 quadrants, no organomegaly, no bruits Pharmacologic Back: Nontender to palpation. No pain with forward flexion of low back but reports some mild dizziness with touching toes. ÑÑStart on 1,000 mcg of vitamin B12 daily for 14 days and then every week for 12 weeks. Then titrate down to monthly. This No CVA tenderness monthly regimen will© probably Jones be required& Bartlett for life. Learning, Nasal vita- LLCGU: Normal pelvic exam © Jones & Bartlett Learning, LLC min B12 is fairly expensive.NOT Patients FOR can SALE use oral OR vitamin DISTRIBUTION B12 as Rectal: Normal vault, good tone,NOT heme-negative FOR SALE stool OR DISTRIBUTION long as absorption is not the issue causing the deficiency, but Neuro: CN II–XII intact. Rhine/Weber normal, Romberg posi- many patients still come in monthly for a vitamin B12 injection. tive. Some difficulty with tandem walking. Paresthesias noted with monofilament testing of bilateral feet, DTR 1+ Nonpharmacologic © Jones & Bartlett Learning, LLC Lab results:© Jones & Bartlett Learning, LLC ÑÑTransfusion is not necessary for this patient. With supple- ÑÑ mentation,NOT FOR her anemiaSALE should OR improve.DISTRIBUTION RBC,NOT Hgb, Hct,FOR WBC, SALE B12 decreased OR DISTRIBUTION ÑÑ ÑÑPlan a colonoscopy within the next day or so. She may also LDH, ALT, MCV, RDW elevated need an upper GI work-up. Her results of the colonoscopy ÑÑPeripheral blood smear (macrocytosis, hyperpigmented will dictate how soon a follow-up colonoscopy is needed. If neutrophils, and giant platelets) © Jones & Bartlettpolyps are Learning,found, she will LLCneed screening every 3 years. © JonesÑ Ñ&Schilling’s Bartlett test Learning,(positive) LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 71 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 71 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 72 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEA: Hypoproliferative OR DISTRIBUTION macrocytic anemia secondary to vitaminNOT deficiency FOR SALE usually ORoccurs DISTRIBUTION over 3 or more years, and by the time B12 deficiency you make the diagnosis, neurologic manifestations may be pres-

Peripheral neuropathy related to vitamin B12 deficiency ent. Also, iron-deficiency anemia (IDA) occurs in about a third of patients with pernicious anemia, which may be a cause for incom- Leukopenia secondary to vitamin B12 deficiency plete response to therapy. Thrombocytopenia secondary© Jones to vitamin & Bartlett B12 deficiency Learning, LLC © Jones & Bartlett Learning, LLC Elevated LDH and ALTNOT secondary FOR to vitaminSALE B 12OR deficiency DISTRIBUTIONGuidelines to DirectNOT Care FOR SALE OR DISTRIBUTION Glossitis due to vitamin B deficiency 12 Centers for Disease Control and Prevention. Recommended P: Begin vitamin B12 supplementation. Refer for dietary consulta- adult immunization schedule, by vaccine and age group. tion to increase vitamin B –rich foods. Schedule colonoscopy, 12 2015. http://www.cdc.gov/vaccines/schedules/hcp/imz/ mammogram, and well-woman exam. Recheck in 1 month. adult.html. Accessed September 16, 2015. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC US Preventive Services Task Force: Published recommen- Health Promotion Issues7–8 NOT FOR SALE OR DISTRIBUTION dations.NOT http://www.uspreventiveservicestaskforce.org/ FOR SALE OR DISTRIBUTION ÑÑSchedule for a mammogram once her anemia is stable. BrowseRec/Index/browse-recommendations. Accessed Sep- ÑÑVaccinations are up-to-date. tember 16, 2015. ÑÑSchedule well-woman exam World Health Organization. Haemogolobin concentrations for the diagnosis of anaemia and assessment of severity. Vi- © Jones &Ñ BartlettÑSchedule cLearning,olonoscopy. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORtamin SALE and Mineral OR DISTRIBUTIONNutrition Information System. Geneva: Remember that anemia is never normal, and the history and World Health Organization; 2011. http://www.who.int/ physical exam are key in narrowing down the diagnosis. Be certain vmnis/indicators/haemoglobin.pdf. Accessed September to carefully review medications for a cause of anemia. Vitamin B12 16, 2015.

Mrs. Smith is a 63-year-old African American female who recently Skin: Several scattered seborrheic keratoses had a ©blood Jones count &done Bartlett at her local Learning, health fair. SheLLC was told to HEENT: PERRLA,© Jones EOMs & Bartlettfull to confrontation. Learning, Normal LLC phar- see her healthcare provider because she had a “low blood count.” ynx without exudates. No JVD or thyromegaly Mrs. SmithNOT is FOR in generally SALE good OR health DISTRIBUTION with a history of degenera- NOT FOR SALE OR DISTRIBUTION CV: S1 and S2 RRR, no murmurs, gallops, or rubs tive joint disease (DJD) of the hips, which necessitated right hip Resp: Clear to auscultation replacement 2 years ago. She takes no daily medications, uses aspirin (ASA) occasionally for “aches and pains,” and has NKDA. Breasts: No masses She donates blood about every 6 months and has never been told Abdomen: Soft, nontender, nondistended. Bowel sounds pres- © Jones &she Bartlett has anemia. Learning, Mrs. Smith has LLC been married for the past 43 years© Jonesent & × Bartlett4 quadrants. Learning, No masses or organomegalyLLC NOT FORand SALE has three OR grown DISTRIBUTION children who are alive and well. She and herNOT FORRectal: SALENormal vault,OR goodDISTRIBUTION tone. No hemorrhoids. Fecal occult husband are retired and live in an isolated area about 90 miles blood testing negative from the health clinic. Vaccinations up-to-date, including tetanus, Neuro: Normal cerebral functioning. Cranial nerves II–XII in- Pneumovax, shingles, and an annual flu shot. Well-woman exam tact. Normal sensory and motor exam, Romberg-normal and mammogram completed last year and all normal. Feels well and denies fatigue, weight© loss,Jones or easy & Bartlettbruising. Denies Learning, chest LLCWhat additional assessments/diagnostics© Jones & do Bartlett you need? Learning, LLC pain, SOB, palpitations, lightheadedness,NOT FOR SALE orthopnea, OR or DISTRIBUTION paroxys- What is the differential diagnosesNOT list? FOR SALE OR DISTRIBUTION mal nocturnal dyspnea (PND). Denies recent upper respiratory What is your working diagnosis? infections. No chronic cough or sputum production. No abdominal pain, weight loss, nausea, vomiting, or diarrhea. Denies bloody Additional Assessments/Diagnostics stools© or Jones mucus in &stools. Bartlett Denies Learning,illicit drug use, LLCdenies tobacco Needed© Jones & Bartlett Learning, LLC use, reports drinks approximately four cocktails per night. NOT FOR SALE OR DISTRIBUTION Mrs. Smith presentsNOT FORwithout SALE symptoms OR of anemiaDISTRIBUTION but with suspi- Physical Exam cion that anemia may be present.1–4,7–8,10–13 Detailed exploration of her medical history, including family history, and laboratory and Vital Signs: BP 138/88, P 96 regular, RR 16, T 97.6, Ht 5'6", Wt diagnostic studies will be important to help narrow the potential 150 lbs cause. She is asymptomatic at this time, which would suggest that © Jones &GEN: Bartlett Healthy-appearing, Learning, enthusiastic LLC woman, very cooperative© Jonesthe anemia & Bartlett is not severe Learning, and has not been LLC a longstanding issue. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 72 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 72 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 3 73 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEEvaluation OR for DISTRIBUTION Mrs. Smith’s suspected anemia shouldNOT FORROS SALE OR DISTRIBUTION include: Focus additional questions on assessment of the impact that her ÑÑRisk factors for anemia: anemia symptoms are having on her activities of daily living as ÑÑAge well as potential clues to the cause of her anemia, including: ÑÑDiet: Exploration© of Jones Mrs. Smith’s & Bartlett diet would Learning, be neces- LLCÑÑFatigue (denies) © Jones & Bartlett Learning, LLC sary to determineNOT dietary FOR intake SALE of vitamin OR B DISTRIBUTION12, folate, ÑÑChest pain (denies) NOT FOR SALE OR DISTRIBUTION and iron ÑÑPalpitations (denies) ÑÑIntestinal disorders: Mrs. Smith denies a history of intesti- ÑÑShortness of breath (SOB) (denies) nal disorders. ÑÑDyspnea on exertion (DOE) (denies) ÑÑChronic diseases: Mrs. Smith denies personal history of Ñ Dizziness (denies) ©chronic Jones disease. & Bartlett Learning, LLC Ñ © Jones & Bartlett Learning, LLC Ñ Headache (denies) ÑNOTÑFemales: FOR Pregnancy, SALE childbirth, OR DISTRIBUTION and dysfunctional uter- Ñ NOT FOR SALE OR DISTRIBUTION Ñ ine bleeding predispose women to anemia. Mrs. Smith is ÑCoolness in hands and feet or paresthesias (denies) postmenopausal and denies any abnormal bleeding. ÑÑWorsening of these symptoms with activity can provide an ÑÑInherited: Mrs. Smith has no history of inherited blood estimate of the severity of her anemia (denies) © Jones & Bartlettdisorders. Learning, LLC © JonesExplore & Bartlett her health history Learning, further, makingLLC note of hints to what ÑÑ NOT FOR SALEBone OR marrow DISTRIBUTION dysfunction such as myelodysplastic syndrome,NOT the FOR cause SALE of anemia OR may DISTRIBUTION be: blood or bone cancers, and marrow suppression by medi- Ñ cations, toxins, or disease: Drugs that can decrease folic ÑETOH use. Administer CAGE questionnaire (Mrs. Smith re- acid measurements include alcohol, aminosalicylic acid ports drinking 4 cocktails per night) (ASA), birth control pills, estrogens, tetracyclines, am- ÑÑMedications that may interfere with absorption such as hor- picillin, chloramphenicol,© Jones erythromycin, & Bartlett methotrexate, Learning, LLCmones, anticonvulsants, antineoplastic© Jones agents& Bartlett (Mrs. Smith Learning, LLC reports using ASA for her DJD) penicillin, aminopterin,NOT FORphenobarbital, SALE phenytoin,OR DISTRIBUTION and NOT FOR SALE OR DISTRIBUTION drugs to treat malaria. ÑÑDiet recall (vegetarian, low intake of B vitamins) (denies) Ñ ÑIdentifiable causes of anemia: Physical Exam ÑÑBleeding: Either chronic or acute blood loss can be the cause of anemia. In the case of Mrs. Smith, she denies any The physical examination for this patient should include: © signsJones or symptoms & Bartlett of upper Learning, gastrointestinal LLC blood loss, ÑÑA thorough© Jones assessment & ofBartlett the heart andLearning, lungs for s/s LLC of car- NOTshe denies FOR any SALE postmenopausal OR DISTRIBUTION bleeding, and her stool diac complicationsNOT FOR of SALEanemia OR(arrhythmias, DISTRIBUTION extracardiac was negative for blood during exam, which lessens the sounds, murmurs or rubs, auscultation of lungs) likelihood that her anemia is related to lower gastrointes- ÑÑEvaluation for fluid overload (peripheral edema, JVD, card iac tinal loss. Depending on her laboratory testing, this cause and lung evaluation) of anemia may need to be explored in addition to other ÑÑAppropriate measurement of blood pressure with verifica- more likely causes. © Jones & Bartlett Learning, LLC © Jonestion & inBartlett the contralateral Learning, arm LLC NOT FOR SALEÑÑDiminished OR DISTRIBUTION red blood cell (RBC) production: LaboraNOT- FOR SALE OR DISTRIBUTION ÑÑPalpation of the lower extremities for edema and peripheral tory testing will determine whether a vitamin defi- pulses ciency is the cause for Mrs. Smith’s diminished blood Ñ counts. ÑExamination of the abdomen for enlarged spleen, liver, changes in kidneys, masses, and abnormal aortic pulsations ÑÑRapid rates of red blood cell destruction: Inherited or ac- Ñ quired diseases that© Jonescause an increased& Bartlett rate ofLearning, RBC de- LLCÑExamination of the skin and© nails Jones for complications & Bartlett of aneLearning,- LLC struction can leadNOT to anemia. FOR Mrs. SALE Smith’s medicalOR DISTRIBUTION history mia (spoon nails [koilonychias])NOT FOR SALE OR DISTRIBUTION does not suggest any of these potential causes nor does ÑÑExamination of the mucous membranes for s/s of anemia her physical examination reveal enlargement or abnor- (pallor, glossitis of the tongue, angular cheilitis of the mouth) mality of the spleen. If other causes are ruled out, further Routine Labs studies for causative agents of hemolytic anemia may be © undertaken.Jones & Bartlett Learning, LLC Routine labs© for Jones Mrs. Smith & shouldBartlett include Learning, those directed LLC at as- NOT FOR SALE OR DISTRIBUTION sessing her anemia.NOT FOR SALE OR DISTRIBUTION ÑÑPresence or absence of complications of anemia: ÑÑArrhythmia (not present) Baseline studies: ÑÑCongestive heart failure (not present) ÑÑComprehensive metabolic panel, including: ÑÑEnd organ damage such as liver and kidney failure (not ÑÑAlbumin (normal) © Jones & Bartlettpresent) Learning, LLC © JonesÑ Ñ&Alkaline Bartlett phosphatase Learning, (normal) LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 73 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 73 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 74 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEÑÑALT OR (alanine DISTRIBUTION aminotransferase) (elevated) NOT FORÑÑEPO: SALE Erythropoietin OR DISTRIBUTION studies may be ordered to determine ÑÑAST (aspartate aminotransferase) (elevated) whether erythropoietin deficiency is the cause of anemia. ÑÑBUN (normal) Not done in this case Ñ ÑÑCreatinine (normal) ÑSchilling’s test: The Schilling’s test is helpful in differentiating vitamin B –deficiency anemia from folic acid–deficiency ÑÑ 12 Calcium (normal)© Jones & Bartlett Learning, LLCanemia. Mrs. Smith’s Schilling’s© Jones test is negative. & Bartlett Learning, LLC ÑÑChloride (normal)NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Potential diagnostic studies: ÑÑCarbon dioxide (normal) ÑÑGlucose (normal) ÑÑColonoscopy for wellness and to r/o occult GI bleed ÑÑPotassium (normal) Differential Diagnoses List Ñ©ÑSodium Jones (normal) & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ÑNOTÑTotal FORbilirubin SALE (normal) OR DISTRIBUTION Folic acid deficiencyNOT FOR SALE OR DISTRIBUTION ÑÑTotal protein (normal) Vitamin B12 deficiency ÑÑComplete blood count, including: Iron-deficiency anemia ÑÑRBC (low) Anemia of blood loss © Jones & BartlettÑÑHgb (low) Learning, LLC © JonesAlcohol & Bartlettabuse Learning, LLC NOT FOR SALEÑÑHct OR (low) DISTRIBUTION NOT FORWorking SALE Diagnoses OR DISTRIBUTION ÑÑMCV (elevated) Anemia due to frequent blood donations ÑÑMCH (normal) Occult GI malignancy (ruled out by colonoscopy) ÑÑMCHC (normal) Alcohol abuse ÑÑPlatelets (low) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Folate deficiency ÑÑWBC (basophils,NOT eosinophils, FOR lymphocytes, SALE OR monocytes, DISTRIBUTION NOT FOR SALE OR DISTRIBUTION neutrophils) (low) Pathophysiology12,13,20 ÑÑUrinalysis (normal) Folate deficiency leads to decreased production of RBCs and Additional anemia studies: resultant anemia. This deficiency can be caused by a diet lack- © Jones & Bartlett Learning, LLC ing in folic ©acid, Jones alcoholism, & Bartlett use of certain Learning, medications, LLC and ÑÑSerum iron (normal) pregnancy. Mrs. Smith’s alcohol consumption would be defined NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ÑÑSerum ferritin (normal) as heavy drinking and would be a substantial risk factor for folic ÑÑTotal iron-binding capacity (TIBC) (normal) acid deficiency. Folate deficiency may occur simultaneously with other forms of anemia such as vitamin B –deficiency and iron- Ñ Vitamin B (normal) 12 Ñ 12 deficiency anemia. ÑÑFolate (low) © Jones &Ñ BartlettÑReticulocyte Learning, count (normal) LLC © JonesWhat & Bartlett Is Your Learning, Treatment LLCPlan? NOT FOR ÑSALEÑRDW (ORelevated) DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pharmacologic ÑÑ Peripheral blood smear (abnormally large RBC—megaloblasts) ÑÑSchilling’s test (negative) ÑÑBegin oral iron therapy. FeSO4 325mg QD. Include client education about the drug © Jones & Bartlett Learning, LLCÑÑDiscuss proper administration© (onJones empty & stomach), Bartlett possibil Learning,- LLC Additional Labs NOTand Diagnostic FOR SALE Testing OR DISTRIBUTIONity of constipation, dark-coloredNOT stools. FOR SALE OR DISTRIBUTION ÑÑLiver function tests: Done as baseline study related to possible ÑÑStart folic acid 0.4 mg PO QD. causes of anemia and potential for alcohol-related changes (elevated) Nonpharmacologic Ñ Ñ Discuss diet to increase foods with iron and folic acid. ÑCho© Joneslesterol panel: & BartlettAdvised to Learning,assess for CVD. LLC Done as base- Ñ © Jones & Bartlett Learning, LLC line study related to Mrs. Smith’s age (normal) Ñ NOT FOR SALE OR DISTRIBUTION ÑFollow-upNOT in 3FOR months SALE to check OR complete DISTRIBUTION blood count ÑÑThyroid studies: If thyroid disease is suspected. Not done in (CBC), folic acid, and BP. Don’t expect return to normal folic this case acid for 2–3 months.

9781284065800_CH05_063_084.indd 74 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 74 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 3 75 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 12,13,19,20 NOT FOR SALEEducation/Counseling OR DISTRIBUTION NOT FORAbdomen: SALE Soft, nontender,OR DISTRIBUTION nondistended. Bowel sounds present × 4 quadrants. No masses or organomegaly ÑÑEncourage no more than two blood donations per year (three blood donations per year is roughly equivalent to Rectal: Normal vault, good tone. No hemorrhoids. Fecal occult the blood loss of normal menses in one year). The Ameri- blood testing negative Neuro: Normal cerebral functioning. Cranial nerves II–XII in- can Red Cross suggests© Jones waiting & about Bartlett 56 days Learning, between LLC © Jones & Bartlett Learning, LLC donations. tact. Normal sensory and motor exam, Romberg-normal NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ÑÑReview other healthy lifestyle issues with her: exercise, stress A: Anemia due to frequent blood donations management, diet Occult GI malignancy (ruled out by colonoscopy) ÑÑDiscuss ETOH use. According to the American Heart Asso- Alcohol abuse ciation (AHA), women should drink no more than 4 oz of Folate deficiency wine,© Jones 12 oz of &beer, Bartlett or 1 oz of Learning, hard liquor daily. LLC Discuss risk P: Colonoscopy© Jones to r/o & GI Bartlett malignancy. Learning, Begin folate LLC0.4 mg ofNOT falls with FOR Mrs. SALE Smith related OR toDISTRIBUTION ETOH use. When consid- PO QDNOT and iron FOR 325 mgSALE PO QD. OR Encourage DISTRIBUTION reevaluation ering referral for ETOH-related issues, consider that the pri- of alcohol consumption and referral to appropriate sup- mary care provider (PCP) is likely to have the best working port/treatment as she is willing. Encourage diet rich in and trusting relationship with the patient. Discuss the ETOH folic acid. issue and the impact ETOH is having on her health. Refer only when the patient is in agreement with the need for this. © Jones & Bartlett Learning, LLC © JonesHealth & Bartlett Promotion Learning, Issues7–8 LLC NOT FOR SALEWithout OR buy-in DISTRIBUTION from the patient, she may not follow throughNOT FOR SALE OR DISTRIBUTION or may be reluctant to share other concerns with you. ÑÑColonoscopy ÑÑVaccinations are up-to-date SOAP Note Guidelines to Direct Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC S: Mrs. Smith is a 63-year-old African American female who NOT FOR SALE OR DISTRIBUTIONAmerican Heart Association.NOT Alcohol FOR and SALE heart ORhealth. DISTRIBUTION reports a low blood count was identified at a local health http://www.heart.org/HEARTORG/GettingHealthy/ fair. She reports a history of degenerative joint disease in NutritionCenter/HealthyEating/Alcohol-and-Heart- her hips that necessitated a right hip replacement 2 years Health_UCM_305173_Article.jsp. Accessed September ago. She takes no daily medications currently, but she 16, 2015. uses aspirin as needed for joint pain. NKDA. She donates © Jones & Bartlett Learning, LLC American ©Red Jones Cross. Donating& Bartlett blood: Learning, eligibility guidelines. LLC blood about every 6 months and has never been told she http://www.redcrossblood.org/donating-blood/eligibility- hasNOT anemia. FOR Mrs. SALE Smith isOR retired, DISTRIBUTION has been married for the NOT FOR SALE OR DISTRIBUTION requirements. Accessed September 16, 2015. past 43 years, and has three grown children who are alive and well. Vaccinations up-to-date; well-woman exam and Centers for Disease Control and Prevention. Recommended mammogram completed last year were normal. Feels well adult immunization schedule, by vaccine and age group. and denies fatigue, weight loss, or easy bruising. Denies 2015. http://www.cdc.gov/vaccines/schedules/hcp/imz/ © Jones & Bartlettchest pain, Learning, SOB, palpitations, LLC lightheadedness, orthopnea,© Jonesadult.html. & Bartlett Accessed Learning, September 16,LLC 2015. NOT FOR SALEor PND. OR No DISTRIBUTION abdominal pain, weight loss, nausea, vomiting,NOT FORNational SALE Institutes OR of DISTRIBUTION Health, National Institute on Alcohol diarrhea, bloody stools, or mucus in stools. Reports she Abuse and Alcoholism. Alcohol use disorder guideline. drinks approximately four cocktails per night, but denies http://www.niaaa.nih.gov/alcohol-health/overview-alcohol- tobacco use or illicit drug use. consumption/alcohol-use-disorders. Accessed September 16, 2015. O: Vital Signs: BP 138/88,© Jones P 96 regular, & BartlettRR 16, T 97.6, Learning, Ht 5'6", LLC © Jones & Bartlett Learning, LLC Wt 150 lbs US Dept of Agriculture, US Dept of Health and Human NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION GEN: Healthy-appearing, enthusiastic woman, very cooperative Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; Skin: Several scattered seborrheic keratoses December 2010. http://health.gov/dietaryguidelines/ HEENT: PERRLA, EOMs full to confrontation. Normal phar- dga2010/dietaryguidelines2010.pdf. Accessed Septem- ynx without exudates. No JVD or thyromegaly ber 16, 2015. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC CV: S1 and S2 RRR, no murmurs, gallops, or rubs US Preventive Services Task Force. Published recommendations. Resp:NOT Clear FOR to auscultation SALE OR DISTRIBUTION http://www.uspreventiveservicestaskforce.org/BrowseRec/NOT FOR SALE OR DISTRIBUTION Breasts: No masses Index/browse-recommendations. Accessed September 16, 2015.

9781284065800_CH05_063_084.indd 75 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 75 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 76 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Case 4

Mr. Snow is a 65-year-old male with progressively increasing SOB anemia.1–4,7–8,10,14–18 Mr. Snow’s history suggests that any of the over the last 2 months. His SOB sometimes occurs at rest and aforementioned causes are plausible. Further exploration, labora- often prevents him from© shopping Jones and & Bartlettwalking up Learning,an incline. LLCtory testing, and diagnostics will© need Jones to be completed & Bartlett to provide Learning, LLC Admitted to the hospitalNOT 6 months FOR ago SALE with an ORepisode DISTRIBUTION of un- clarity and direct treatment. NOT FOR SALE OR DISTRIBUTION stable angina that did not progress to acute myocardial infarction (AMI). Takes 325 mg ASA, 50 mg atenolol, and 40 mg simvas- ROS tatin since his recent admission. Denies any other chronic medi- Focus additional questions on assessment of the impact that his cal problems or surgeries. NKDA. Smoked 20 cigarettes daily × anemia symptoms are having on his activities of daily living as well 30 years.© JonesStopped “cold& Bartlett turkey” after Learning, recent hospital LLC admission. as potential clues© Jones to the cause & Bartlettof his anemia, Learning, including: LLC RarelyNOT sees a healthcareFOR SALE provider. OR Does DISTRIBUTION not believe in immuniza- NOT FOR SALE OR DISTRIBUTION ÑÑChest pain (denies) tions. Denies fever or rashes. No pruritus or skin color changes. Ñ Denies chest pain (CP), palpitations, or dizziness. Reports pro- ÑPalpitations (denies) gressively increasing SOB both at rest and with exertion. Denies ÑÑShortness of breath (SOB) (Mr. Snow reports SOB) cough, sputum production, wheezing, orthopnea, or PND. De- ÑÑDyspnea on exertion (DOE) (Mr. Snow reports DOE) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC nies weight change. No abdominal pain, nausea, or vomiting. ÑÑDizziness (denies) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Denies bloody or mucous stools. ÑÑHeadache (denies) Physical Exam ÑÑCoolness in hands and feet or paresthesias (denies) Ñ Nausea/vomiting (denies) Vital Signs: BP 120/70, HR 56 regular, RR 14, T 98.5, Ht 6'0", Ñ Wt 165 lbs ÑÑWorsening of these symptoms with activity can provide an © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC GEN: Alert and cooperative. In no apparent distress. estimate of the severity of his anemia NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION HEENT: Head normocephalic without evidence of masses or Further discussion of cardiovascular risk factors should also be trauma. PERRLA, EOMs full to confrontation. Noninjected. explored, including: Fundoscopic exam unremarkable with exception of pale reti- ÑÑHTN: None noted nal background. Palpebral conjunctiva pale. Ear canal with- Ñ out redness or irritation, TM clear, pearly, bony landmarks ÑCigarette smoking: Mr. Snow is a former smoker but is not © Jones & Bartlett Learning, LLC currently© Jones & Bartlett Learning, LLC visible.NOT No FOR discharge, SALE no painOR noted. DISTRIBUTION Pale nasal mucosa. Pos- NOT FOR SALE OR DISTRIBUTION terior pharynx pale. Neck: Supple without masses. No thyro- ÑÑObesity: Mr. Snow has a normal body mass index megaly. No JVD noted ÑÑPhysical inactivity: Mr. Snow does not exercise Skin: No discoloration, no open areas or abnormalities noted ÑÑDyslipidemia: Present but under treatment by cardiologist

CV: S1 and S2 regular with a soft aortic ejection murmur in the ÑÑDiabetes mellitus: You will need to order labs © Jones & Bartlettaortic area. Learning, No radiation LLCto carotids or axilla. No JVD. No© JonesÑÑAge: & MBartlettr. Snow is 65Learning, years old LLC peripheral edema NOT FOR SALE OR DISTRIBUTION NOT FORÑÑFamily SALE history: OR When DISTRIBUTION queried further he reports his mother Lungs: Minimal scattered rhonchi that resolve with coughing and father both had HTN and CVD. This is a significant risk Abdomen: Bowel sounds present in all quads. Abdomen soft factor with no organomegaly Evaluation for Suspected Anemia Rectal: Normal vault, good tone, heme-positive stool © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Neuro: Normal cerebral functioning. CN II–XII intact. Normal ÑÑRisk factors for anemia: sensory and motor exam,NOT Romberg FOR negativeSALE OR DISTRIBUTIONÑÑAnemia risk increases withNOT age. FORAlthough SALE the exact OR etiol DISTRIBUTION- ogy of anemia in elderly persons may be multifactorial, What additional assessments/diagnostics do you need? advancing age is a known risk factor for anemia. What is the differential diagnoses list? ÑÑA diet that is deficient in quality protein sources and B vi- What© isJones your working & Bartlett diagnosis? Learning, LLC tamins© isJones a known & risk Bartlett factor for Learning,anemia. Hematopoiesis LLC AdditionalNOT FOR Assessments/DiagnosticsSALE OR DISTRIBUTION requiresNOT healthy FOR levels SALE of macronutrients OR DISTRIBUTION and micronutri- ents in order to carry out cell production and maturation. Needed ÑÑIntestinal disorders such as malabsorptive disorders, para- Mr. Snow presents with symptoms that are troubling and sitism, lack of intrinsic factor, gastric bypass surgery, Crohn’s may be attributable to respiratory disease, cardiac causes, or disease, and ulcerative colitis increase the risk of anemia. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 76 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 76 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 4 77 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEÑÑChronic OR diseasesDISTRIBUTION such as thyroid, liver, kidney, or autoimNOT- FORÑÑExa minationSALE ORof the DISTRIBUTION abdomen for enlarged spleen, liver, mune diseases as well as HIV/AIDS and cancer increase changes in kidneys (either enlarged or smaller than antici- the risk of anemia. pated), masses, and abnormal aortic pulsations. None noted. ÑÑPregnancy, childbirth, and dysfunctional uterine bleeding ÑÑExamination of the skin and nails for complications of anemia predispose women to anemia. and kidney disease (pruritus, spoon nails [koilonychias]). ÑÑInherited diseases© suchJones as sickle & Bartlettcell disease Learning, or trait as LLCNone noted. © Jones & Bartlett Learning, LLC well as the thalassemiasNOT can FOR interfere SALE with productionOR DISTRIBUTION and ÑÑExamination of the mucousNOT membranes FOR SALE for s/s ORof ane DISTRIBUTION- maturation of red blood cells. mia (pallor, glossitis of the tongue, angular cheilitis of the ÑÑBone marrow dysfunction such as myelodysplastic syn- mouth). Pallor noted. drome, blood or bone cancers, and marrow suppression Labs ©by Jones medications, & Bartlett toxins, or Learning, disease increase LLC the risk for © Jones & Bartlett Learning, LLC anemia. Mr. Snow is under the care of a cardiologist since his hospital NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ÑÑIdentifiable causes of anemia: admission 6 months ago, when his cholesterol panels were com- ÑÑBleeding: Either chronic or acute blood loss can be the pleted and a medication regimen initiated. Laboratory evaluation cause of anemia. In the case of Mr. Snow, he does have at this visit should focus on those issues that may be contributing symptoms of lower gastrointestinal blood loss because to his increasing SOB. © Jones & Bartletthis stool Learning, was positive LLCfor blood during examination to©- JonesÑÑD-dim & Bartletter: D-dimer Learning, may be completed LLC if a pulmonary embo- NOT FOR SALEday. OR This DISTRIBUTION potential cause of his anemia will need to be exNOT- FORlism SALE (PE) is suspected.OR DISTRIBUTION Mr. Snow is not acutely SOB and is plored with further diagnostic studies. in no apparent distress, so this cause is unlikely. The D-dimer ÑÑDiminished red blood cell (RBC) production: Mr. Snow’s may be elevated with inflammation from a number of causes, history does not suggest this as a potential cause of his so false positives are possible. This evaluation was not done anemia. If other causes are ruled out, further studies may for this patient at this visit. need to be completed.© Jones & Bartlett Learning, LLCÑÑWBC: Will be completed ©as Jonespart of CBC & Bartlett to evaluate Learning, for LLC ÑÑRapid rates of redNOT blood FORcell destruction: SALE InheritedOR DISTRIBUTION or ac- potential of infection NOT FOR SALE OR DISTRIBUTION quired diseases that cause an increased rate of RBC destruction can lead to anemia. Mr. Snow’s medical history Routine Labs does not suggest any of these potential causes nor does his Routine labs for Mr. Snow should include those directed at assess- physical examination reveal enlargement or abnormality ing for anemia, infection, and end organ function. © ofJones his spleen. & IfBartlett suspected, Learning, laboratory studies LLC to rule out © Jones & Bartlett Learning, LLC Baseline studies: NOTsickle FOR cell disease SALE and ORthalassemia DISTRIBUTION should be performed. NOT FOR SALE OR DISTRIBUTION If other causes are ruled out, further studies for causative ÑÑComprehensive metabolic panel, including: agents of hemolytic anemia may be undertaken. ÑÑAlbumin (normal) ÑÑPresence or absence of complications of anemia: ÑÑAlkaline phosphatase (normal) ÑÑ ÑÑALT (alanine aminotransferase) (normal) © Jones & BartlettArrhythmia Learning, LLC © Jones & Bartlett Learning, LLC ÑÑ ÑÑAST (aspartate aminotransferase) (normal) NOT FOR SALECongestive OR DISTRIBUTION heart failure NOT FOR SALE OR DISTRIBUTION ÑÑEnd organ damage such as liver and kidney failure ÑÑBUN (normal) ÑÑCreatinine (normal) Physical Exam ÑÑCalcium (normal) The physical examination for this patient should include: ÑÑChloride (normal) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ÑÑA thorough assessment of the heart and lungs for s/s of car- ÑÑCarbon dioxide (normal) diac complications ofNOT anemia FOR and kidneySALE disease OR DISTRIBUTION(arrhyth- ÑÑGlucose (normal) NOT FOR SALE OR DISTRIBUTION mias, extracardiac sounds, murmurs or rubs, auscultation of ÑÑPotassium (normal) lungs). Mr. Snow has an ejection murmur. ÑÑSodium (normal) Ñ Evaluation for fluid overload (peripheral edema, JVD, car- Ñ ÑÑTotal bilirubin (normal) diac and lung evaluation). None noted. © Jones & Bartlett Learning, LLC ÑÑTotal© protein Jones (normal) & Bartlett Learning, LLC ÑÑAppropriate measurement of blood pressure with verifi- NOT FOR SALE OR DISTRIBUTION Ñ NOT FOR SALE OR DISTRIBUTION cation in the contralateral arm. Mr. Snow has a normal BP ÑComplete blood count, including: bilaterally. ÑÑRBC (low) ÑÑPalpation of the lower extremities for edema and peripheral ÑÑHgb 11.9% (low) pulses. None noted. ÑÑHct 38% (low) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 77 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 77 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 78 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEÑÑMCV OR (low DISTRIBUTION normal) NOT FORWorking SALE Diagnosis OR DISTRIBUTION ÑÑMCH (normal) Anemia related to subclinical bleeding due to ASA use ÑÑMCHC (normal) COPD ÑÑPlatelets (normal) Hyperlipidemia ÑÑWBCs (basophils, eosinophils, lymphocytes, monocytes, © Jones & Bartlett Learning, LLCEjection murmur © Jones & Bartlett Learning, LLC neutrophils) (normal)NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Additional kidney function studies: Pathophysiology ÑÑUrinalysis (UA) (normal) Iron-deficiency anemia can be caused by a low-iron diet, loss of blood, impaired iron absorption, or loss of body stores of iron that Additional anemia studies: have been depleted by disease states.18 Early iron-deficiency anemia ÑÑSer©um Jones iron (low) & Bartlett Learning, LLC (IDA) is characterized© Jones by a &normocytic, Bartlett possibly Learning, hypochromic LLC anemia with progression to a microcytic hypochromic anemia in later ÑÑSerNOTum ferritin FOR (low) SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION phases. In the case of Mr. Snow, his anemia has been precipitated Ñ Total iron-binding capacity (TIBC) (high) Ñ by ASA use and a subclinical GI bleed and is in an early phase, ac- Ñ ÑVitamin B12 (Not completed for Mr. Snow) cording to his lab values. With correction of the underlying disease ÑÑFolate (Not completed for Mr. Snow) process and iron supplementation, his anemia should correct. © Jones &Ñ BartlettÑReticulocyte Learning, count (elevated) LLC © Jones & Bartlett Learning, LLC NOT FOR ÑSALEÑRDW (ORelevated) DISTRIBUTION NOT FORWhat SALE Is Your OR TreatmentDISTRIBUTION Plan? ÑÑPeripheral blood smear (variably sized with some abnormally shaped and some hypochromic RBC noted) Pharmacologic Additional Labs ÑÑBegin iron supplementation with FeSO4 at 325 mg PO QD. © Jones & Bartlett Learning, LLCÑÑModify ASA regimen to 81© mg Jones QD. ASA & would Bartlett be recom Learning,- LLC ÑÑCholesterol panel—completed at prior hospitalization. Med- NOT FOR SALE OR DISTRIBUTIONmended in this patient r/t NOThis murmur FOR and SALE for CVD, OR but DISTRIBUTION if ications managed by cardiologist the bleeding continues, further consultation with the cardi- ÑÑThyroid studies—not completed for Mr. Snow ologist would need to be initiated to determine risk/benefit ÑÑEPO—not completed for Mr. Snow of continued therapy. Simply reducing the ASA is the easiest and most cost-effective plan. Proton pump inhibitor therapy Diagnostics should include: © Jones & Bartlett Learning, LLC is not indicated© Jones because & ofBartlett lack of GI Learning,symptoms.7–8,15,17–18 LLC Ñ In-office EKG—unchanged from prior studies Ñ NOT FOR SALE OR DISTRIBUTION NonpharmacologicNOT FOR SALE OR DISTRIBUTION ÑÑChest X-ray to rule out pneumonia and evaluate cardiac size and anatomical structures of lungs—negative for pneumonia, ÑÑConsider pulmonary function testing to determine whether cardiac silhouette normal, lung with changes noted consistent further treatment is indicated for his COPD. with COPD ÑÑKeep normal follow-ups with cardiology. © Jones &Ñ BartlettÑColonoscopy—Mr. Learning, Snow LLC has blood in his stool per the© JonesÑÑCongr & Bartlettatulate him Learning,on decision to quitLLC smoking and encourage NOT FOR SALEtest during OR theDISTRIBUTION examination. Further evaluation is necesNOT- FORhim SALEto stay the OR course. DISTRIBUTION sary to rule out malignancy, determine extent of ongoing ÑÑContinue follow-up (f/u) with cardiologist. blood loss. 10,12,14–16 Differential Diagnoses Education/Counseling ÑÑDiet education with an emphasis on iron-rich foods Chronic obstructive pulmonary© Jones disease & Bartlett (COPD)—smoker, Learning, LLC © Jones & Bartlett Learning, LLC Ñ rhonchi NOT FOR SALE OR DISTRIBUTIONÑEducation regarding s/s of worseningNOT FOR SALE OR DISTRIBUTION Ñ Cardiac failure—left sided, angina ÑMedication education—when and how to take, side effects (constipation). Change in color of stool, nausea Anemia—ASA, diet, pallor, ejection murmur ÑÑEducate patient on pursed-lip breathing and COPD manage- Poor physical conditioning ment goals Asthma© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC PneumoniaNOT FOR SALE OR DISTRIBUTION SOAP NOTNote FOR SALE OR DISTRIBUTION PE—may occur in the absence of coughing up blood S: Mr. Snow is a 65-year-old male with a 2-month history of GI bleeding—subclinical bleeding, has been taking ASA for progressively increasing SOB at rest and worsening dys- past 6 months pnea on exertion. Mr. Snow was hospitalized for unstable © Jones &Ejection Bartlett murmur Learning, LLC © Jonesangina & Bartlett without MI Learning, 6 months ago LLC and was started on ASA NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 78 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 78 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 5 79 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE325 mg, OR atenolol DISTRIBUTION 50 mg, and simvastatin 40 mg daily.NOT FORand SALEfollowing OR lipid DISTRIBUTIONmanagement and ejection murmur. Will NKDA. 30-pack-year history of tobacco use but stopped start Mr. Snow on FeSo4 325 mg PO QD today, continue on “cold turkey” after recent hospital admission. Rarely sees atenolol and simvastatin ordered by cardiologist. Education pro- a healthcare provider. Does not believe in immunizations. vided regarding COPD management, health management, and Denies fever or rashes. No pruritus or skin color changes. immunization recommendations today. Mr. Snow verbalized Denies CP, palpitations,© Jones or dizziness. & Bartlett Denies cough, Learning, sputum LLCunderstanding of topics discussed© Jones but currently & Bartlett refuses vaccina Learning,- LLC production, wheezing,NOT orthopnea, FOR SALEor PND. ORDenies DISTRIBUTION weight tion for prevention of shingles,NOT pneumonia, FOR influenza, SALE tetanus. OR DISTRIBUTION change, abdominal pain, nausea, vomiting, or bloody or mu- 7–8,12 cous stools. Health Promotion Issues O: Vital Signs: BP 120/70, P 56 regular, RR 14, T 98.5, Ht 6'0", ÑÑEncourage routine follow-ups for health maintenance. Wt 165 lbs Ñ Encourage routine cardiology follow-up. © Jones & Bartlett Learning, LLC Ñ © Jones & Bartlett Learning, LLC GEN: Alert and cooperative. In NAD ÑÑImmunizations recommended: shingles, pneumonia, influ- HEENT:NOT Head FOR normocephalic SALE OR without DISTRIBUTION evidence of masses or enza, tetanus.NOT FOR SALE OR DISTRIBUTION trauma. PERRLA, EOMs full to confrontation. Noninjected. Fundoscopic exam unremarkable with exception of pale reti- Guidelines to Direct Care nal background. Palpebral conjunctiva pale. Ear canal with- Centers for Disease Control and Prevention. Recommended out redness or irritation, TM clear, pearly, bony landmarks © Jones & Bartlett Learning, LLC © Jonesadult & Bartlettimmunization Learning, schedule, by vaccineLLC and age group. 2015. visible. No discharge, no pain noted. Pale nasal mucosa. Pos- http://www.cdc.gov/vaccines/schedules/hcp/imz/adult NOT FOR SALEterior pharynxOR DISTRIBUTION pale. Neck supple without masses. No thyroNOT- FOR SALE OR DISTRIBUTION .html. Accessed September 16, 2015. megaly. No JVD noted Qaseem A, Humphrey LL, Fitterman N, et al. Treatment of ane- Skin: No discoloration, no open areas or abnormalities noted mia in patients with heart disease: a clinical practice guide- S and S regular with a soft aortic ejection murmur in the CV: 1 2 line from the American College of Physicians. Ann Intern aortic area. No radiation to carotids or axilla. No JVD. No © Jones & Bartlett Learning, LLCMed. December 3, 2013;159(11):770–779.© Jones & Bartlett Learning, LLC peripheral edema NOT FOR SALE OR DISTRIBUTIONUS Dept of Agriculture, US DeptNOT of FORHealth SALEand Human OR Ser DISTRIBUTION- Lungs: Minimal scattered rhonchi that resolve with coughing vices. Dietary Guidelines for Americans, 2010. 7th ed. Washing- Abdomen: Bowel sounds present in all quads. Abdomen soft ton, DC: US Government Printing Office; December 2010. with no organomegaly http://health.gov/dietaryguidelines/dga2010/dietary Rectal: Normal vault, good tone, heme-positive stool © Jones & Bartlett Learning, LLC guidelines2010.pdf.© Jones Accessed & Bartlett September Learning, 16, 2015. LLC Neuro:NOT Normal FOR cerebral SALE functioning. OR DISTRIBUTION CN II–XII intact. Normal US PreventiveNOT Services FOR Task SALE Force. Published OR DISTRIBUTION recommendations. sensory and motor exam, Romberg negative http://www.uspreventiveservicestaskforce.org/Browse ECG: Unchanged Rec/Index/browse-recommendations. Accessed September Labs: Normocytic, hypochromic anemia consistent with IDA 16, 2015. Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the A: Anemia related to subclinical bleeding due to ASA use diagnosis, management, and prevention of chronic obstruc- © Jones & BartlettCOPD Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORtive SALEpulmonary OR disease. DISTRIBUTION 2013. http://www.goldcopd.org/ Hyperlipidemia uploads/users/files/GOLD_Report_2013_Feb20.pdf Ejection murmur World Health Organization. Haemogolobin concentrations for P: Mr. Snow presents today with subclinical lower GI bleeding the diagnosis of anaemia and assessment of severity. Vitamin secondary to ASA therapy resulting in IDA. Mr. Snow’s history and Mineral Nutrition Information System. Geneva: World and physical examination© Jones are also significant & Bartlett for hyperlipidemia, Learning, LLCHealth Organization; 2011.© Joneshttp://www.who.int/vmnis/ & Bartlett Learning, LLC ejection murmur, andNOT COPD. FOR Cardiology SALE is alreadyOR DISTRIBUTION involved indicators/haemoglobin.pdf.NOT Accessed FOR September SALE 16, OR 2015. DISTRIBUTION

Case© Jones 5 & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC LatishaNOT is a 38-year-oldFOR SALE African OR American DISTRIBUTION woman who presents the end of theNOT workday. FOR She SALE reports ORno changes DISTRIBUTION in her diet. She to the clinic for a new patient physical examination. Latisha is denies nausea, vomiting, or diarrhea. She has not noted any dark concerned about persistent mild fatigue, which she reports has stools or blood in her stools but admits to an occasional mild been gradually worsening for the last 6 months. She has noted a nosebleed. She also mentions that her menstrual flow has been © Jones &gradual Bartlett decrease Learning, in her work tolerance LLC and feels “washed out” at© Jonesa little heavier& Bartlett than usual Learning, for the past LLCseveral months. She denies NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 79 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 79 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 80 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORcold SALE intolerance, OR muscleDISTRIBUTION weakness, fever, chills, or joint pain. SheNOT FORHEENT: SALE Palpebral OR DISTRIBUTIONconjunctivae are pale bilaterally. No began to take over-the-counter vitamins, one tablet a day, 2 weeks lymphadenopathy

ago. She reports feeling a bit better since she started her vitamins. CV: S1 and S2 RRR, no murmurs, gallops, or rubs Past Medical History Lungs: Clear to auscultation Breasts: No masses or tenderness Allergies: NKDA © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONAbdomen: Soft, nontender, no NOTorganomegaly FOR SALE OR DISTRIBUTION Medical illnesses: HTN, hx of depression treated 5 years ago with Neuro: Unremarkable no reoccurrences Extremities: Unremarkable Normal vaginal delivery 10 years ago Hospitalizations: Pelvic: Normal S/P laparoscopic tubal ligation at the age of 33 Rectal: Normal vault, no hemorrhoids, stool negative for occult Medications:© Jones Vasotec & Bartlett 10 mg daily Learning, LLC blood © Jones & Bartlett Learning, LLC MultivNOTitamin FOR with SALE iron daily OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION What additional assessments/diagnostics do you need? ASA 1 tablet 325 mg daily What is the differential diagnoses list? Family History What is your working diagnosis? © Jones &Latisha Bartlett was born Learning, in the United LLC States. Her parents are natives of© Jones & Bartlett Learning, LLC NOT FORAlgeria. SALE No OR family DISTRIBUTION history of sickle cell disease, diabetes, kidneyNOT FORAdditional SALE OR Assessments/Diagnostics DISTRIBUTION disease, HTN, cancer, or thyroid disease. Needed Further exploration of Latisha’s history should include explora- Social History tion of the following:1–4,7,8,18,19 Her parents are college professors.© Jones Latisha & Bartlett has one brother Learning, who is LLCÑÑWhat is the reason for taking© ASA Jones (Latisha & reportsBartlett she takesLearning, LLC alive and well and attends a local high school. Latisha is employed NOT FOR SALE OR DISTRIBUTIONASA for “heart health,” butNOT it was FOR not ordered SALE by ORanother DISTRIBUTION at a local insurance company. She denies any changes in her work, healthcare provider.) home, or social life. She is a nonsmoker and a nondrinker. She de- ÑÑMore info regarding her nosebleeds, diet, menstrual flow, nies illicit drug use. headache, palpitations, fever, or sore throat (Latisha denies headache, palpitations, fever, or sore throat) Health© Jones Promotion & Bartlett History Learning, LLC © Jones & Bartlett Learning, LLC Latisha’sNOT immunizations FOR SALE are up-to-date, OR DISTRIBUTION including tetanus. She has The followingNOT lab FORstudies SALEshould be OR completed: DISTRIBUTION never had a mammogram. She does SBE occasionally. She only Baseline studies: sees her healthcare provider when she has a problem. ÑÑComprehensive metabolic panel, including: Focused ROS ÑÑAlbumin (normal) ÑÑAlkaline phosphatase (normal) © Jones &General: Bartlett Denies Learning, weight loss, LLC night sweats, muscle aches, joint© Jones & Bartlett Learning, LLC ÑÑALT (alanine aminotransferase) (normal) NOT FOR SALEpain, lymphadenopathy, OR DISTRIBUTION or fever NOT FOR SALE OR DISTRIBUTION ÑÑAST (aspartate aminotransferase) (normal) HEENT: Occasional mild nosebleed ÑÑBUN (normal) CV: Denies chest pain, leg swelling, and palpitations ÑÑCreatinine (normal) Resp: Denies SOB, DOE, or orthopnea. No cough or recent re- ÑÑ spiratory tract infections© Jones & Bartlett Learning, LLC Calcium (normal) © Jones & Bartlett Learning, LLC ÑÑ GI: Denies nausea, vomiting,NOT FORdiarrhea, SALE melena, OR or DISTRIBUTIONblood in Chloride (normal) NOT FOR SALE OR DISTRIBUTION her stools ÑÑCarbon dioxide (normal) GU: Denies polydipsia, polyuria, or polyphagia. Increase in ÑÑGlucose (normal) menstrual flow for the past several months ÑÑPotassium (normal) ÑÑ © Jones & Bartlett Learning, LLC Sodium© Jones (normal) & Bartlett Learning, LLC Physical Exam ÑÑ NOT FOR SALE OR DISTRIBUTION TotalNOT bilirubin FOR (normal) SALE OR DISTRIBUTION Vital Signs: BP 110/88, P 82 (regular), RR 14, T 99, Ht 5'2", Wt ÑÑTotal protein (normal) 135 lbs ÑÑComplete blood count, including: GEN: Alert, oriented × 3, well nourished, in no acute distress ÑÑRBC (normal) Skin: Normal distribution, normal skin turgor, no rashes ÑÑHgb (low) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 80 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 80 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services Case 5 81 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEÑÑHct OR (low) DISTRIBUTION NOTSymptoms FOR SALE range ORfrom DISTRIBUTIONasymptomatic carrier states to fatal ill- ÑÑMCV (low) ness. Adult hemoglobin is made up primarily of alpha and beta ÑÑMCH (low) chains. Thalassemia is most often seen in persons of African, Asian, Mediterranean, or Middle Eastern descent. The thalas- ÑÑMCHC (low) semias are among the most common inherited disorders. Prob- ÑÑ Platelets (normal)© Jones & Bartlett Learning, LLClems result from ineffective erythropoiesis.© Jones Thalassemia& Bartlett minor Learning, LLC ÑÑWBC (basophils,NOT eosinophils, FOR lymphocytes, SALE OR monocytes, DISTRIBUTION usually goes unrecognized untilNOT adulthood FOR and SALE is found OR on rou DISTRIBUTION- neutrophils) (normal) tine lab evaluation. It is a hypochromic and microcytic anemia Additional kidney function studies: and is most easily confirmed by hemoglobin electrophoresis, which would demonstrate an elevated A2 level, increased levels Ñ ÑUrinalysis (UA) (normal) of hemoglobin F, or both. In some patients, the diagnosis can Additional© Jones anemia & studies:Bartlett Learning, LLC be confirmed© by Jones a family &tree Bartlett showing the Learning, presence of anemia,LLC NOT FOR SALE OR DISTRIBUTION microcytosis,NOT or splenomegaly. FOR SALE OR DISTRIBUTION ÑÑSerum iron (normal) ÑÑSerum ferritin (normal) What Is Your Treatment Plan? ÑÑTotal iron-binding capacity (TIBC) (normal) ÑÑReticulocyte count (normal) Pharmacologic © Jones &Ñ Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ÑRDW (normal) ÑÑDiscontinue the multivitamin (MVI). MVI with iron is not NOT FOR ÑSALEÑPeripheral OR blood DISTRIBUTION smear (nucleated target cells, poikilocytoNOT- FORindicated SALE for Latisha’sOR DISTRIBUTION alpha thalassemia. sis, microcytic, hypochromic RBC) ÑÑContinue vasotec. 1–4,7–8,19 Additional labs: ÑÑDiscontinue ASA. Not indicated for this patient. Ñ ÑThyroid studies—if ©thyroid Jones disease & Bartlettis suspected. Learning, Not done LLCNonpharmacologic © Jones & Bartlett Learning, LLC for Latisha Ñ Refer to hematology. Latisha should be referred to hema- Ñ NOT FOR SALE OR DISTRIBUTIONÑ NOT FOR SALE OR DISTRIBUTION ÑHemoglobin electrophoresis—this test will determine tology for development of a monitoring plan and possible whether thalassemia is present. Latisha’s results were elevated genetic counseling. Thalassemia is dependent on the ethnic A2 level and increased levels of Hgb F consistent with alpha origins of the client. B-thalassemia is seen in clients of Greek thalassemia and Italian descent most commonly, and A-thalassemia is © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Differential Diagnoses seen most commonly in African Americans, American Indi- NOT FOR SALE OR DISTRIBUTION ans, andNOT Asians. FOR SALE OR DISTRIBUTION Iron-deficiency anemia—Latisha is of reproductive age with monthly blood loss, making iron-deficiency anemia the most Education/Counseling likely cause. Because of the microcytic hypochromic indices, The importance of diagnosing thalassemia minor lies in the ge- the megaloblastic anemias can be ruled out. netic information obtained because it does not require therapy. © Jones &Thalassemia—Latisha’s Bartlett Learning, parents LLC are from the “thalassemia belt,”© JonesSometimes & Bartlett lab data may Learning, indicate IDA, LLC but iron is not needed un- NOT FOR SALEso this OR diagnosis DISTRIBUTION needs to be considered during the evaluaNOT- less FOR there SALE is excessive OR blood DISTRIBUTION loss. In fact, iron therapy is harmful tion process. because iron overload may cause organ damage. It is very impor- Lead exposure—there are no apparent risk factors, but with the tant that this patient is educated to avoid all iron (FE) supple- information you currently have from your evaluation it is a ments and foods high in FE. possibility. © Jones & Bartlett Learning, LLCSOAP Note © Jones & Bartlett Learning, LLC Anemia of chronic disease—not likely based upon current information. NOT FOR SALE OR DISTRIBUTIONS: Latisha is a 38-year-old AfricanNOT AmericanFOR SALE woman OR of AlDISTRIBUTION- gerian descent who presents to the clinic for a new patient Hypertension—well controlled on current regimen. physical examination. Latisha is concerned about persis- Working Diagnoses tent worsening fatigue. Latisha denies nausea, vomiting, diarrhea, dark stools, or blood in her stools but admits Alpha© Jonesthalassemia & Bartlett Learning, LLC to an occasional© Jones mild & nosebleedBartlett andLearning, heavier than LLC usual HypertensionNOT FOR SALE OR DISTRIBUTION menstrualNOT periods. FOR She SALE denies OR cold DISTRIBUTION intolerance, muscle weakness, fever, chills, or joint pain. She began to take Pathophysiology an over-the-counter MVI, one tablet a day, 2 weeks ago. Thalassemia is a group of hereditary anemias caused by ab- She reports feeling a bit better since she started taking the normalities on the protein chains that make up hemoglobin.19 MVI. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284065800_CH05_063_084.indd 81 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 81 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services 82 CHAPTER 5 | Common Hematologic Disorders in Primary Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEO: Vital Signs:OR BPDISTRIBUTION 110/88, P 82 (regular), RR 14, T 99, Ht 5'2",NOT FORand SALEMVI. Follow OR up DISTRIBUTION in 6 months to reevaluate HTN and dis- Wt 135 lbs cuss results and understanding of information from hematol- GEN: Alert, oriented × 3, well nourished, in no acute distress ogy consultation. Skin: Normal distribution, normal skin turgor, no rashes Health Promotion Issues HEENT: Palpebral conjunctivae© Jones &are Bartlett pale bilaterally. Learning, No LLC © Jones & Bartlett Learning, LLC lymphadenopathy ÑÑEmphasize importance of health maintenance and routine NOT FOR SALE OR DISTRIBUTIONfollow-up. NOT FOR SALE OR DISTRIBUTION CV: S1 and S2 RRR, no murmurs, gallops, or rubs Ñ Discuss alpha thalassemia and provide basic education prior Lungs: LCTA Ñ to hematology consultation. Breasts: No masses or tenderness Abdomen: Soft, nontender, no organomegaly Guidelines to Direct Care Neuro:© JonesUnremarkable & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Centers for Disease Control and Prevention. Recommended Extremities:NOT FOR Unremarkable SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION adult immunization schedule, by vaccine and age group. Pelvic: Normal 2015. http://www.cdc.gov/vaccines/schedules/hcp/imz/ Rectal: Normal vault, no hemorrhoids, stool negative for occult adult.html. Accessed September 16, 2015. blood US Preventive Services Task Force. Published recommendations. © Jones &Labs: Bartlett Nucleated Learning, target cells, LLC poikilocytosis on smear. Micro©- Joneshttp://www.uspreventiveservicestaskforce.org/BrowseRec/In & Bartlett Learning, LLC - NOT FOR SALEcytic, hypochromicOR DISTRIBUTION anemia. Hgb electrophoresis consistentNOT FORdex/browse-recommendations. SALE OR DISTRIBUTION Accessed September 16, 2015. with alpha thalassemia World Health Organization. Haemogolobin concentrations for A: Alpha thalassemia the diagnosis of anaemia and assessment of severity. Vitamin Hypertension and Mineral Nutrition Information System. Geneva: World Health Organization; 2011. http://www.who.int/vmnis/ P: Patient presents with© alpha Jones thalassemia. & Bartlett Refer to hematologyLearning, LLC © Jones & Bartlett Learning, LLC for further evaluation. Continue vasotec. Discontinue ASA indicators/haemoglobin.pdf. Accessed September 16, 2015. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Conclusion Keep ©in mindJones that &the Bartlett signs and symptoms Learning, of anemia LLC are caused deficiency. You© Jonesshould suspect & Bartlett anemia if Learning,your patient complains LLC by decreasedNOT FORdelivery SALE of oxygen OR to peripheralDISTRIBUTION tissues. Anemia is of dizziness, NOTexertional FOR dyspnea, SALE fatigue, OR headaches, DISTRIBUTION loss of libido, a common problem in primary care with dietary issues as a fre- mood changes, sleep problems, tinnitus, weakness, glossitis, jaun- quent causation. The leading cause of anemia in the United States dice, neuropathy, pallor, peripheral edema, splenomegaly, tachy- is iron deficiency, followed by folate deficiency and vitamin B12 cardia, hemic murmur, or pica.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORREFERENCES SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. American Society of Hematology. For patients: anemia. 2010. chronic kidney disease. Kidney Int Suppl. August 2012;2(4):279–335. http://www.hematology.org/Patients/Anemia/. Accessed Septem- http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO- ber 8, 2015. Anemia%20GL.pdf. 2. Makipopur S, Kanapuru© JonesB, Ershler & WB. Bartlett Unexplained Learning, anemia LLC6. Kidney Disease: Improving Global© Jones Outcomes & (KDIGO) Bartlett Anemia Learning, LLC in the elderly. SeminNOT Hematol. FOR October SALE 2008;45(4):250–254. OR DISTRIBUTION Work Group. KDIGO 2012 clinicalNOT practice FOR guideline SALE for theOR evalu DISTRIBUTION- doi:10.1053/j.seminhematol.2008.06.003. ation and management of chronic kidney disease. Kidney Int Suppl. 3. National Heart, Lung, and Blood Institute. What is anemia? 2013;(3):1 http://www.kdigo.org/clinical_practice_guidelines/pdf/ 2012. http://www.nhlbi.nih.gov/health/health-topics/topics/ CKD/KDIGO_2012_CKD_GL.pdf. anemia/. 7. US Preventive Services Task Force. Screening recommendations. 4. World© Jones Health Organization. & Bartlett Haemogolobin Learning, concentrations LLC for the http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/© Jones & Bartlett Learning, LLC diagnosis of anaemia and assessment of severity. 2011. http://www browse-recommendations. .who.int/vmnis/indicators/haemoglobin.pdf.NOT FOR SALE OR DISTRIBUTION 8. Centers forNOT Disease FOR Control SALE and Prevention. OR DISTRIBUTION Recommended adult 5. Kidney Disease: Improving Global Outcomes (KDIGO) Ane- immunization schedule, by vaccine and age group. 2014. http:// mia Work Group. KDIGO clinical practice guideline for anemia in www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.

9781284065800_CH05_063_084.indd 82 DESIGN SERVICES OF 13/01/16 4:16 AM # 159813 Cust: JBL Au: Thanavaro Pg. No. 82 K S4CARLISLE Title: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners, 1e Short / Normal Publishing Services References 83 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR 9.SALE Langan ORR, Zawistoski DISTRIBUTION K. Update on vitamin B12 deficiency. AmNOT 15. FOR Vestbo SALE J, Hurd SS,OR Agustí DISTRIBUTION AG, et al. Global strategy for the diagno- Fam Physician. 2011;83(12):1425–1430. http://www.aafp.org/ sis, management, and prevention of chronic obstructive pulmonary afp/2011/0615/p1425.html. disease. 2013. http://www.goldcopd.org/uploads/users/files/ 10. US Dept of Agriculture and US Dept of Health and Human Services. GOLD_Report_2013_Feb20.pdf. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US 16. Johnson-Wimbley TD. Diagnosis and management of iron defi- Government Printing Office;© Jones 2010. & Bartlett Learning, LLCciency anemia in the 21st century.© Jones Therap Adv & GastroenterolBartlett. Learning,May LLC 11. Ghadban R, Almourani R. Folate (folic acid). 2014. http:// 2011;4(3):177–184. http://www.ncbi.nlm.nih.gov/pmc/articles/ emedicine.medscape.com/article/2085523-overview.NOT FOR SALE OR DISTRIBUTIONPMC3105608/. NOT FOR SALE OR DISTRIBUTION 12. American Heart Association. Alcohol and heart health. January 17. Short MW, Domagalski JE. Iron deficiency anemia: evaluation and 12, 2015. http://www.heart.org/HEARTORG/GettingHealthy/ management. Am Fam Physician. 2013;87(2):98–104. http://www NutritionCenter/HealthyEating/Alcohol-and-Heart-Health_ .aafp.org/afp/2013/0115/p98. UCM_305173_Article.jsp. 18. Piel FB, Weatherall DJ. The a-thalassemias. N Engl J Med. 13. Nat©ional Jones Institutes & Bartlettof Health, Learning, National Institute LLC on Alco- 2014;371(20):1908–1916.© Jones & Bartlett Learning, LLC holNOT Abuse FOR and Alcoholism. SALE OR Alcohol DISTRIBUTION use disorder. http://www 19. AmericanNOT Red Cross. FOR Eligibility SALE requirements. OR DISTRIBUTION February, 2015. .niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/ http://www.redcrossblood.org/donating-blood/eligibility- alcohol-use-disorders. requirements. 14. Qaseem A, Humphrey LL, Fitterman N, et al. Treatment of ane- 20. National Institutes of Health, National Institute on Alcohol mia in patients with heart disease: a clinical practice guideline from Abuse and Alcoholism. Alcohol use disorder guideline. February, the American College of Physicians. Ann Intern Med. December 3, 2015. http://www.niaaa.nih.gov/alcohol-health/overview-alcohol- © Jones & Bartlett2013;159(11):770–779. Learning, LLC © Jonesconsumption/alcohol-use-disordersConclusion & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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