Family Medicine 26_ 55-year-old man with fatigue

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Aquifer Case Study Family Medicine 26: 55-year-old man with fatigue Gurpreet Sandhu United States University FNP 595: Primary Health of Acute Clients/ Families Across the Lifespan Professor Dr. Tiffany Glass 12/06/2022 In this instance, Mr. Cunha, a 55-year-old male Portuguese, presents with two months of increased

weariness that is not relieved by rest. His work and relationships are suffering, and he calls it crippling. Mr. Cunha also acknowledges that, for the past 12 months, defecation has made his rectal bleeding worse. Apart from tachycardia and pale conjunctiva, his physical examination revealed no signs of depression. Considerations for his presentation include obstructive sleep apnea (OSA), anemia, and malignancy (Slowik & Collen,2020). The "most likely" cause of iron deficiency anemia in adult males is lower GI hemorrhage, which is indicated by bright red blood in the stool (Slowik & Collen,2020). He needs more testing to see whether he has cancer, but this diagnosis is his persistent lethargy, chronic rectal bleeding, and lack of a colonoscopy history (Amin & Catiele,2019). He does not have many other risk factors, even though his snoring, exhaustion, and palpitations indicate OSA as a diagnosis. He does not use drugs, does not smoke, has a good BMI, and is young (Slowik & Collen, 2020). However, fatigue is a common complaint among the elderly, affecting longevity and daily functioning in the very old. This study assesses the relationship between fatigue and health, functional status, and mortality in people between the ages of 70 and 88 (Sakinah et al.,2022). There are many various types of weariness, and they vary by population. Most patients who appear with fatigue in primary care lack a clear biological etiology (e.g., cancer or anemia). The prevalence of psychological and physiological causes— such as depression and substance abuse—and primary sleep disorders—such as sleep disruption—is typically higher than secondary causes. Nevertheless, depending on a patient's history, risk factors, and physical exam results, secondary causes of fatigue resulting from biological causes are common enough in all groups to justify careful evaluation and focused testing (Sakinah et al.,2022). Also, diagnosing some secondary causes is critical because they may be harmful. Given his lethargy, pale conjunctiva, tachycardia, palpitations, and increased rectal bleeding, a CBC, CMP, iron tests, chest X-ray, TSH, and colonoscopy are all necessary (Amin & Catiele,2019). Intensive anemia was found in Mr. Cunha's lab results, and invasive adenocarcinoma was found during the colonoscopy and pathology. An oncologist referral is necessary. For anemia, a 100 mg oral iron supplement per day is advised (Amin & Catiele,2019). Despite the referral, it is still crucial to be involved in his care and see that his needs are addressed by his family provider (Amin & Catiele,2019).

Mr. Cunha must be closely monitored, especially as his cancer is being treated. While he waits for his follow-up exam and oncologist visit, he should know that any chest pain, worsening symptoms, shortness of breath, diaphoresis, confusion, and so on require urgent medical attention. Family caregivers can still take an active part in their care by communicating with the oncologist, helping the patient make treatment decisions, and assisting in managing side effects (Amin & Catiele,2019).

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References: Amin, S. K., & Catiele Antunes. (2019, April 11). Lower Gastrointestinal Bleeding . Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448126/ Kumar, R., & Lewis, C. R. (2021). Colon Cancer Screening . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559064/ Sakinah Baharudin, N., Salwa Talib, S., Farahsyahirah, N., Nor, M., Azri, M., Ainuddin, H., Zamir, A., & Daud, C. (2022). Assessing Socio-Demographic Factors Affecting Fatigue Level among Community- Dwelling Older People. ESTEEM Journal of Social Sciences and Humanities , 6 (2), 133–146. https://ejssh.uitm.edu.my/images/Vol6Sept22/HWB18174_EJSSHVOL6_2_SEPT2022.pdf Slowik, J. M., & Collen, J. F. (2020). Obstructive Sleep Apnea . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459252/ Warner, M. J., & Kamran, M. T. (2018, November 14). Anemia, Iron Deficiency . Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448065/

Case Analysis Tool Worksheet Student's Name: Gurpreet K Sandhu Case ID: Family Medicine 26: 55-year-old man with fatigue I. Epidemiology/Patient Profile Mr. Cunha, a 55-year-old cisgender male who does not smoke and occasionally consumes alcohol, has been complaining of fatigue for the past two months. II. Prioritized Cues from Hx and PE. (Do not include lab, x-ray, or other diagnostic test results here.) • Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem. • Tier 2: These are cues of intermediate importance (list only positive cues). • Tier 3: Of least importance (list only positive cues). Tier 1 Tier 2 Tier 3 Increasing weariness over the past two months, which hasn't improved with rest. No signs of a fever, chills, loss of weight, intolerance to heat or cold, daytime tiredness, polyuria, polydipsia, headache, visual changes, tinnitus, hearing issues, nasal congestion, nosebleeds, difficulty swallowing, lumps in the neck, chest pains, cough, wheezing, hemoptysis, jaundice, nausea, vomiting, diarrhea, or constipation. Temperature: 37 °C Pulse: 102 beats/minute RR: 16 breaths/minute BP: 126/76 mmHg Weight: 80.7 kgs Height: 183 cm BMI: 24.1 kg/m2 unable to complete responsibilities at work or having an impact on home life Denies using drugs or smoking; uses alcohol occasionally. denies allergies or using medications, palpitations during exertion denies experiencing hematuria, epistaxis, or bloody hiccups, No prior hospitalizations, operations, or medical history. On physical examination, tachycardia and pale conjunctiva are noticed. Family medical history: Father died at age 77 from a myocardial infarction. Mother is still alive at age 81; She has osteoarthritis and high blood pressure. Each sibling is in good health. No family history has ever had cancer initial visit after three years.

He snores, according to the wife. Social background: He resides with his wife of 26 years. Two local grown children who are of legal age. He owns and operates his family's roofing contractor, where his wife and two kids are also employed. Hemorrhoids that have worsened in the past year Daily blood in stools III. Problem Statement Mr. Cunha, a 55-year-old Portuguese man, has been having palpitations with exertion for the past two months, and his career and social life are being affected by his increased weariness, which is not improved by rest. As his hemorrhoids have worsened over the past two years, he has also reported painless, bright red rectal bleeding daily. This is his first visit in three years, and neither a medical nor surgical history exists. On physical examination, the doctor notes tachycardia and pale conjunctiva. IV. Differential Diagnosis Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis. Leading dx:

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D50. 9: Iron deficiency anemia Hemoglobin levels below the mean for the patient's age and gender are considered frail. The hemoglobin A molecule requires iron as a key ingredient. Iron deficiency, which produces microcytic and hypochromic red cells on the peripheral smear, is the most typical cause of anemia globally. According to age, gender, and socioeconomic situation, many causes of iron Insufficiency exist. Unspecific complaints from the patient, like weariness and dyspnea with exercise, are frequent. Reversing the underlying problem and taking Extra iron are both forms of treatment. Although oral supplementation with iron is most frequently needed, there are several situations where intravenous iron may be necessary. History Finding(s) Physical Exam Finding(s) two months of worsening weariness that hasn't improved with rest General survey: Male who presents well and is in good physical shape. Daily occurrence of blood in stools BMI: 24.1 kg/m2 unable to complete responsibilities at work or having an impact on home life Ferritin 7 ng/mL MCV 67.8 μm3 Hgb 6.7 g/dL Hct 22% Serum Iron 48 μg/dL Total Iron BC 398 ug/dL Hemorrhoids in the past that have gotten worse in the past year On physical examination, tachycardia and pale conjunctiva are noticed. Denies having a fever, chills, changing weight, N/V/D, polyuria, polydipsia, or HA palpitations during exertion denies experiencing hematuria, epistaxis, or bloody hiccups. Alternative dx:

C18. 9 - Malignant neoplasm of the colon (Kumar & Lewis,2021) The screening process involves checking for cancer in asymptomatic people. There are numerous methods for screening for colorectal cancer. Stool-based tastes and visual examinations can be used to categorize these tests. A colonoscopy performed to identify any colon cancer or other abnormalities. Early detection of colon cancer typically results in a better prognosis for the patient. History Finding(s) Physical Exam Finding(s) Daily occurrence of blood in stools Ferritin 7 ng/mL MCV 67.8 μm3 Hgb 6.7 g/dL Hct 22% Serum Iron 48 μg/dL Total Iron BC 398 ug/dL two months of worsening weariness that hasn't improved with rest Colonoscopy pathology results reveal invasive cancer. Unable to complete responsibilities at work or have an impact on home life Abdomen: Soft, non-tender, and no distended. Bowel sounds are present in all quadrants. No palpable masses of Hemorrhoids in the past that have gotten worse in the past year. On physical examination, tachycardia and pale conjunctiva are noticed. Denies having a fever, chills, changing weight, N/V/D, polyuria, polydipsia, or HA palpitations during exertion denies experiencing hematuria, epistaxis, or bloody hiccups

Alternative dx: G47.33: Obstructive Sleep Apnea He does not have many other risk factors, even though his snoring, exhaustion, and palpitations indicate OSA as a diagnosis. He does not use drugs, does not smoke, has a good BMI, and is young (Slowik & Collen, 2020). Unrest causes fragmented, nonrestorative sleep as a result. Other signs include observed sleep apneas, loud, bothersome snoring, and excessive daytime tiredness The effects of OSA on psychological health, cardiovascular health, quality of life, and driving safety are profound. History Finding(s) Physical Exam Finding(s) The patient snores, according to the wife. BMI: 24.1 kg/m2 Palpitations during exertion. On physical examination, tachycardia and pale conjunctiva are noticed. Unable to complete work responsibilities or impact home life Chest: Clear to bilateral auscultation on the chest. no wheezing, no additional noises, two months of worsening weariness that hasn't improved with rest General: Well-appearing, physically good in shape. Medication: Do not take any prescription or over- the-counter drugs. No herbal remedies No known medical allergies. Neck: No bruits, thyromegaly, or adenopathy V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order: Diagnostic Plan Rationale Complete Blood Count (CBC) It is significant because Mr. Cunha had blood in his stools and was pale when examined (Warner & Kamran,2018). Iron studies with ferritin Because of rectal bleeding, it is necessary ( Warner

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& Kamran,2018). Serum glucose To verify diabetes Erythrocyte sedimentation rate (ESR) is crucial since the likelihood of undetected cancer is very high (Warner & Kamran,2018). Cancer screening tests To confirm colorectal cancer (Warner & Kamran,2018). Anoscope To verify hemorrhoids (Kumar & Lewis,2021) Colonoscopy To check for colon (Kumar & Lewis,2021) Treatment Plan Rationale prescribe iron supplements daily. Iron supplementation is required for at least three months to replenish tissue iron stores. It should also continue for at least one month after hemoglobin has returned to normal levels (Warner & Kamran,2018). To treat iron deficiency Stool softeners are daily ( Warner & Kamran,2018). To prevent constipation Refer the patient for a colonoscopy For investigation of the colon (Kumar & Lewis,2021) Follow Up Within one month, pending diagnostics and oncology visit. I have adhered to the honor system:

Student's signature Gurpreet K Sandhu

Family Medicine 26_ 55-year-old man with fatigue

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