Iron Consultation
Date: 1 November 2024
Reason for Consultation
- Patient referred for evaluation of iron deficiency and consideration of intravenous iron infusion.
History of Presenting Illness
- Patient presents with fatigue, weakness, and shortness of breath for the past three months.
- Patient reports experiencing fatigue/weakness, shortness of breath, and pale skin.
Iron Related Medical History:
- Patient has a history of iron deficiency anemia diagnosed two years ago, treated with oral iron supplements.
- Patient reports heavy menstrual bleeding.
Past Medical History:
- Hypertension, well-controlled with medication.
Allergies: No known allergies.
Medications: Lisinopril 10mg daily, Ferrous Sulfate 325mg daily (discontinued).
Family History:
- Mother with a history of iron deficiency anemia.
Dietary and Lifestyle Factors:
- Patient reports a vegetarian diet.
Supplements:
- Patient previously taking Ferrous Sulfate 325mg daily, but discontinued due to side effects.
Social History
- Non-smoker.
- Drinks alcohol occasionally.
Physical examination:
- Patient appears well and in reasonably good health.
- Pale conjunctiva noted.
Initial Investigation results
- Labs: CBC: Hemoglobin 10.2 g/dL, Ferritin 10 ng/mL, Transferrin Saturation 8%, TIBC elevated.
Assessment:
- Iron deficiency anemia.
Goals for Management:
- Patient goals: To improve energy levels and resolve symptoms of iron deficiency.
Management Plan:
- Discussed the patient's iron status and the need for iron replacement.
- Patient will be started on an iron infusion.
Iron Infusion:
- Patient will receive an iron infusion of 1000mg of iron sucrose.
- Follow-up labs (CBC, ferritin, TSAT) in six weeks.
- Follow up with results.
- Will send the patient home with a repeat lab requisition including CBC, ferritin, and TSAT six weeks post-infusion and will follow up on the results.
Thank you for referring this patient to discuss their iron deficiency and possible assessment of an infusion.
Reason for Consultation
- [Brief description of the presenting issue or complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of Presenting Illness
- [Details of the reason for visit, current issues including relevant signs and symptoms, as well as associated signs and symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Include patient symptoms consistent with iron deficiency including: Fatigue/weakness, Shortness of breath, Dizziness/lightheadedness, Pale skin, Irregular heartbeat, Cold extremities, Pica (cravings for non-food items), any additional symptoms related to iron deficiency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Iron Related Medical History:
- [History of Iron Deficiency/Anemia, include details of previous diagnosis, treatments, and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [History of blood loss including heavy menstruation, GI bleeding, recent surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Pregnancy profile if applicable indicate current or recent pregnancy status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [List relevant conditions to iron deficiency first such as GI disorders, CKD, celiac disease, followed by secondary medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History:
- [Any known chronic medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Details of previous surgeries or hospitalizations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies: [Any known allergies, particularly to medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications: [Current medications and dosages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History: [Relevant Family History: Any family history of anemia, iron-related disorders, or other hematological conditions or GI history including celiac, inflammatory bowel disease] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Dietary and Lifestyle Factors: [Diet including red meat intake, caloric restriction, vegetarian diet] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Supplements: [Indicate whether the patient is currently taking oral iron supplementation such as Fera-Max or other supplements including brand, dosage, and duration. Indicate if any difficulties or side effects of taking medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History
- [Current or past smoking history (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Alcohol consumption habits (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Any illicit drug use (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current or previous occupation (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History
- [Relevant family medical history (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical examination:
[State that the patient appears well and in reasonably good health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[General state of health and any notable findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Initial Investigation results
- Labs [Start with labs including CBC, ferritin, transferrin saturation, total iron-binding capacity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Other Investigations: [ECG, ultrasound, etc. (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
- [Presumed diagnosis based on consult summary] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnosis (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Goals for Management:
Patient Goals: [Example: rapidly replace iron stores, optimize oral iron strategies, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Management Plan: [Discuss the patient's iron status and potential options for iron replacement. If the patient has not tried oral supplements, we will start them on feramax pro 150 mg two tabs every other day] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Iron Infusion: (If the patient has trialed oral iron, we will start them on an iron infusion.) [List the dosage discussed and follow-up treatment program including follow-up labs, follow-up infusions as needed, and further investigations. If there is no specified follow-up plan, please state we will repeat the iron labs listed above and ensure levels have returned to normal levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Add that we will send the patient home with a repeat lab requisition including CBC, ferritin, and TSAT six weeks post-infusion and will follow up on the results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)