Which test(s) should be performed to determine whether the anemia is related to chronic disease or iron deficiency, and what would those results show?

The test that should be performed to determine whether the anemia of this patient is related to chronic disease or iron deficiency is serum ferritin levels.  If serum ferritin level is less than 30 mg/L iron deficiency is pathological (Dunphy et al., 2022).  If anemia is related to chronic disease, lab results show a low serum iron level, low total iron-binding capacity (TIBC), yet serum ferritin levels are typically normal or elevated (Dunphy et al., 2022).  When serum ferritin levels decrease, hemoglobin concentrations also decrease resulting in anemia at the end stage of severe iron deficiency (Jefferds et al., 2022). 

Should the practitioner consider a blood transfusion for this patient? Explain your answer.

Blood transfusions are typically considered for patients if Hct is 27% or less, but must be carefully considered (Dunphy et al., 2022).  This patient has a history of congestive heart failure and reduced kidney function, although current labs indicate that it is not worsening.  She has a Hct of 29%, and is symptomatic, presenting with complaints of fatigue, shortness of breath after activity, her heart rate is elevated at 92, and respirations 28, and she appears pale, but her blood pressure is 138/72.  Given her history and current status, along with Hct of 29% I would not transfuse at this time. 

Which medication(s) should be considered for this patient? Provide exact prescription details.

Iron-deficiency anemia is typically treated with increased dietary iron and iron supplementation if dietary iron is not sufficient.  Iron-rich foods including spinach, animal proteins, and legumes are recommended (Dunphy et al., 2022).  Medication that should be considered for this patient is ferrous sulfate 325mg PO TID taken on empty stomach for anemia (Dunphy et al., 2022). 

What considerations should the practitioner include in the care of the patient if an erythropoietic agent is used for treatment? What risks are involved with the use of erythropoietic agents?

Hemoglobin levels must be monitored when a patient receives an erythropoietic agent for treatment and should be checked two times a week for 2 to 6 weeks after a dose increase.  Erythropoietic agents have the risk of a dangerous rise in hemoglobin, and treatment should be held if hemoglobin exceeds 12g/dL or increases more than 1g/dL in 2 weeks (Dunphy et al., 2022). 

What follow-up should the practitioner recommend for the patient?

RBC levels and iron values should be assessed 2 to 4 weeks after starting treatment to determine adherence and effectiveness, and then the patient should continue supplement for 3 to 6 months after levels have improved.  If the patient does not respond to treatment, they may need a referral to a specialist depending on the underlying cause of anemia.  Possible specialists include a hematologist, gastroenterologist, or oncologist (Dunphy et al., 2022).

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