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gestalt/Pre-consult

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  • Referral, hematologyScanned 08:14
  • Lab results, CBCReceived 07:52
  • Consult letterFaxed yesterday

Pre-consult summary

Iron deficiency anemia, not responding to oral iron

History
25-year-old man. No significant past medical history. No GI symptoms reported in the referral.
Prior results
Hemoglobin, March98 g/L
Hemoglobin, June85 g/L
MCV71 fL
Ferritin5 µg/L
To clarify at the visit
Adherence to and tolerance of oral iron. Diet, NSAID use and any GI blood loss. Family history of celiac or GI disease.

Transcript

  1. PhysicianHow has your energy been since you started the iron?
  2. PatientAbout the same. I still get winded on the stairs.
  3. PhysicianAny stomach upset with the pills?
  4. PatientSome, so I have been skipping doses.
  5. PhysicianAny black stools or blood when you go to the bathroom?
  6. PatientNo, nothing like that.

Draft note

Hematology consult

Subjective

3 months of fatigue and exertional dyspnea. Started oral iron 6 weeks ago; GI upset with missed doses. No melena or hematochezia. No NSAID use.

Objective

HR 92, BP 118/74. Conjunctival pallor. Abdomen soft, non-tender.

Hb 85 g/L, MCV 71 fL, ferritin 5 µg/L.

Assessment/Plan

In summary, Patient is a 25M presenting with iron deficiency anemia.

1. Iron deficiency anemia (Hb 85)

  • Repeat CBC, ferritin and reticulocyte count
  • Celiac serology (tTG-IgA)ASH
  • Refer to gastroenterology for endoscopic evaluationASH
  • Switch to alternate-day oral iron; IV iron if not tolerated or no responseASH
  • Recheck hemoglobin in 4 weeks

Guideline recommendation

In men with iron deficiency anemia, evaluate for a gastrointestinal source of blood loss, including celiac disease.

American Society of Hematology (ASH)

Sent to patient

Your care plan from today: what we discussed, the tests booked, and when to expect a call. Reminder set for your bloodwork.

Follow-up

3 open

Illustrative example. Not real patient data.

By doctors, for doctors, and above all for patients.

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