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Please read the case below and determine the diagnosis. “I’ve been feeling really lousy lately. I have no energy whatsoever and I’m always cranky.” HPI: (History of Present Illness) W.L. is an 80 y/o man who presents to the Veterans Administration Hospital for a routine checkup. Upon questioning, he states that he “has been feeling weak and terrible” for nearly six months now but has not experienced any loss in weight. PMH (Past Medical History) • Multiple DVT with chronic venous insufficiency • Type 2 DM • HTN • Hyperlipidemia • Prostate cancer S/P prostatectomy • S/P CVA • DJD; hip fracture 7 years ago; chronic pain in the lower back and right buttock • Mild memory loss • Chronic allergic rhinitis • Seizure disorder x 17 years; no seizures with medication in 3 years • COPD x 11 years Vital Sign: BP: 130/85, P: 110, RR: 18, T: 97.8F, BMI: 28.1 Please see the attached lab. Hct 19.7 % Hb 8.8 mg/dL RBC 3.0 Plt 139 MCV 103 fL MCHC 33.5 Fe 67 TIBC 312 Transferrin saturation 39 % Ferritin 124 ng/ml Vitamin b12 250 pg/ml Folate 1.7 ng/ml bilirubin 1.2
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HEALTH SCIENCE
NURSING

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