Case 7

A 51 yo woman is being evaluated for anemia. She has a long history of anemia dating back to high school. She was given red cell transfusions on two previous occasions, following the birth of her daughter 30 years ago and again following open heart surgery 4 months ago. She had been prescribed oral iron pills in the past but was unable to tolerate these because of GI side effects

Past history

Hodgkin lymphoma, diagnosed 25 years ago and treated with chemotherapy and radiotherapy. She has been in remission since completing treatment.
Valvular heart disease (possibly a complication of radiation treatments for lymphoma) necessitating replacement of the aortic and mitral valves with metal St Jude valves, and repair of the tricuspic valve, 4 months ago. Her anemia worsened following the surgery and she has received a total of 12 units of red cells since then. She has been treated with an anticoagulant (warfarin) since this procedure to prevent clot formation on the valves.
Hypothyroidism, status post thyroidectomy for thyroid cancer (possibly also a complication of radiation for lymphoma) 7 years previously, treated
Hypoparathyroidism, treated
History of splenectomy, done as part of a staging evaluation for Hodgkin disease 25 years ago.

Medications

Amiodarone
Albuterol-ipratropium inhaler
Simvastatin
Alprazolam
Aspirin
Levothyroxine
Calcitriol
Esomeprazole
Warfarin

Family history

Her mother had anemia of uncertain cause. No other family history of hematologic disease. Both parents had coronary artery disease.

Social History

Married, one daughter. Never smoked. Consumes alcohol rarely.

Review of systems

Has felt severely fatigued following heart surgery, with some improvement after red cell transfusion. Recent weight gain attributed to fluid retention caused by heart problems, treated with diuretics. No fever, chills. Had been amenorrheic since receiving chemotherapy for lymphoma, but had an episode of vaginal bleeding following heart surgery. Scheduled to see a gynecologist for further evaluation. Has noted occasional dark or black stools.

Physical examination

BP 99/64, pulse 93, temp 36.7, resp 18. Not icteric, no oral lesions. Jugular venous pressure appears increased. Metallic S1/S2, regular rhythm. Scattered lung wheezes. Abdomen obese with surgical scar in left upper quadrant. 1+ pitting edema of ankles.

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