Cellular, and Hematologic Disorders – Case Study

Need help with this case study,Cardiovascular, Cellular, and Hematologic Disorders – Case StudyPart One:INITIAL HISTORY:Tom is a 47 year old male who presents with gradual onset of dyspnea on exertion and fatigue. He also complains of frequent dyspepsia with nausea and occasional epigastric pain. So far you only know that he has a history of alcohol abuse.Discussion question part one:What questions would you like to ask this patient about his symptoms?Part Two He says he has not had his usual energy levels for months; dyspnea has become much worse in the last few weeks which is why he came in. Tom denies chest pain, orthopnea, edema, cough, wheezing, or recent infections. He states he has occasional episodes of hematemesis after drinking heavily, and subsequently has had several days of dark stools. Tom consumes up to 2 six-packs of beer a day for the past 8 years since losing his job. Nothing seems to make his breathing any better, but antacids help with is epigastric discomfort and dyspepsia.PAST MEDICAL HISTORY:Denies history of cardiac or pulmonary diseaseDiagnosed with duodenal ulcer in the past and was on “3 drugs at once” for a while 2 years ago, but stopped taking them due to the expenseHis only surgical history was a childhood tonsillectomyDe does not smoke or take any medications except for over the counter antacidsHe has no known allergiesPHYSICAL EXAMINATION:Thin and pale white male looking older than his stated age with no acute distressT = 37 C orally; P = 95 and regular; RR = 16 and unlabored; B/P = 128/72 sittingSkin, HEENT, Neck:Skin pale without rash, no spider angiomataSclera pale with no icterusPERRLA, fundi without lesionsPharynx is clear without postnasal drainageNO thyromegaly, adenopathy, or bruitsLungs, Cardiac:Good lung expansion, lungs clear to auscultation and percussionPMI at 5th intercostal space at midclavicular lineHeart rhythm regular with a grade II/VI systolic ejection murmur at left sternal borderNo gallops, heaves, or thrillsAbdomen, Rectal:Abdomen nondistended; bowel sounds presentLiver 8 cm. At midclavicular lineModerate epigastric tenderness without rebound or guardingProstate not enlarged and nontenderStool guaiac positiveExtremities, Neurological:No joint deformity, muscle tenderness or edemaAlert and oriented X 3Strength is 5/5 throughout and sensation intactGait normal. DTR 2 + and symmetrical throughoutDiscussion questions part two:What are the pertinent positives and negatives on examination related to his presenting problem?What is your differential diagnosis at this time?What laboratory studies should be obtained at this time?Part ThreeLABORATORY RESULTS:WBC = normal with a normal differential and platelet countHct = 29%; MCV = normal, MCHC = slightly decreased; RDW = markedly increased; reticulocyte count < 2%Smear with mixed microcytic/hypochromic and macrocytic/normochromic red blood cells; WBC and platelets appear normalPT/PTT, liver function tests, electrolytes, and amylase normalUpper endoscopy with 2 cm. duodenal ulcer with evidence of recent but no acute hemorrhageADDITIONAL LABORATORY RESULTS:Serum iron, total iron binding capacity, saturation, and ferritin all reducedBone marrow biopsy with megaloblastic changes and low iron storesØ Serum folate and red blood cell folate low; B12 normalDiscussion questions part three:Based on these findings, what are the diagnoses for this patient?How should this patient be managed?