What is the diagnosis for a 32-year-old female, 10 years post sleeve gastrectomy with chronic gastritis (treated with Nexium (esomeprazole) as needed), heterozygote factor V Leiden mutation, presenting with apathy, fatigue, muscle weakness, insomnia, depression, anxiety, and adipsia, with findings of hypotension, bradycardia, and dark orange/brown urine, and a history of deficiencies in vitamin B12, folate (B9), and iron?

From the Guidelines

The patient's presentation suggests a complex interplay of nutritional deficiencies, potential endocrine abnormalities, and possible gastrointestinal pathology, necessitating a comprehensive diagnostic workup to guide management. Given her history of sleeve gastrectomy and chronic gastritis, along with symptoms of apathy, fatigue, muscle weakness, insomnia, depression, anxiety, and adipsia, a thorough evaluation is crucial. The findings of hypotension, bradycardia, and dark orange/brown urine further support the need for a detailed investigation.

Diagnostic Approach

The diagnostic approach should include:

• A complete blood count with differential to assess for anemia, which is common after bariatric surgery and could explain her fatigue and hypotension 1.
• Comprehensive metabolic panel to evaluate electrolyte imbalances, kidney, and liver function.
• Vitamin B12, folate, iron studies (including ferritin, TIBC, and transferrin saturation) to assess for deficiencies, which are prevalent in post-bariatric surgery patients and can cause fatigue, weakness, and neurological symptoms 1.
• Vitamin D and other micronutrients commonly depleted after bariatric surgery, such as zinc, copper, and selenium, should also be evaluated.
• Thyroid function tests (TSH, free T4) are important as hypothyroidism could explain many of her symptoms.
• A urinalysis is necessary to investigate the dark urine, which could indicate dehydration, liver issues, or myoglobinuria.
• Inflammatory markers (CRP, ESR) to assess for chronic inflammation.
• Coagulation studies given her Factor V Leiden mutation.
• Cortisol levels should be measured to rule out adrenal insufficiency, which could explain her hypotension and fatigue.
• Checking vitamin B1 (thiamine) is important as deficiency can cause neurological symptoms.

Consideration of Recent Guidelines

Recent guidelines, such as those from the British Society of Gastroenterology for the management of iron deficiency anemia in adults 1, and the AGA clinical practice update on the management of iron deficiency anemia 1, emphasize the importance of investigating the underlying cause of iron deficiency anemia, which could be related to gastrointestinal pathology, including malabsorption or chronic blood loss. The AGA clinical practice update on the diagnosis and management of atrophic gastritis also highlights the need to evaluate for anemia due to vitamin B-12 and iron deficiencies in patients with histology compatible with autoimmune gastritis 1.

Priority of Investigations

Given the complexity of her presentation, prioritizing investigations that could quickly identify life-threatening conditions or those that significantly impact her quality of life is essential. This includes assessing for adrenal insufficiency, evaluating her thyroid function, and investigating the cause of her anemia and dark urine. The patient's history of sleeve gastrectomy and chronic gastritis treated with Nexium (esomeprazole) as needed, along with her heterozygote factor V Leiden mutation, should be considered in the context of her current symptoms and findings.

Conclusion of Diagnostic Approach

In summary, a comprehensive diagnostic approach is necessary to evaluate this patient's complex presentation, focusing on identifying potential nutritional deficiencies, endocrine abnormalities, and gastrointestinal pathology that could be contributing to her symptoms. This approach should be guided by recent clinical guidelines and prioritize investigations that could quickly identify conditions impacting her morbidity, mortality, and quality of life.

From the FDA Drug Label

PRECAUTIONS General Vitamin B12 deficiency that is allowed to progress for longer than 3 months may produce permanent degenerative lesions of the spinal cord. Laboratory Tests During the initial treatment of patients with pernicious anemia, serum potassium must be observed closely the first 48 hours and potassium replaced if necessary Hematocrit, reticulocyte count, vitamin B12, folate and iron levels should be obtained prior to treatment.

The patient's symptoms such as apathy, fatigue, muscle weakness, insomnia, depression, anxiety, and adipsia, along with findings of hypotension, bradycardia, and dark orange/brown urine, and a history of deficiencies in vitamin B12, folate (B9), and iron may be related to a vitamin B12 deficiency. However, the provided drug labels do not directly support a diagnosis for this patient. Given the patient's 10-year history post sleeve gastrectomy and chronic gastritis, malabsorption of essential nutrients, including vitamin B12, is likely. Key considerations for this patient include:

• Vitamin B12 deficiency: The patient has a history of deficiency in vitamin B12, which can cause neurological manifestations if left untreated 2.
• Folate deficiency: The patient also has a history of folate deficiency, which can be related to the symptoms presented 2.
• Iron deficiency: Iron deficiency can also contribute to the patient's symptoms, such as fatigue and weakness. It is essential to re-evaluate the diagnosis and treatment of this patient, considering the potential for malabsorption and deficiencies in essential nutrients.

From the Research

Patient Presentation

The patient is a 32-year-old female, 10 years post sleeve gastrectomy, presenting with:

• Apathy
• Fatigue
• Muscle weakness
• Insomnia
• Depression
• Anxiety
• Adipsia
• Hypotension
• Bradycardia
• Dark orange/brown urine
• History of deficiencies in vitamin B12, folate (B9), and iron
• Heterozygote factor V Leiden mutation
• Chronic gastritis (treated with Nexium (esomeprazole) as needed)

Possible Diagnoses

Based on the patient's symptoms and history, possible diagnoses include:

• Electrolyte imbalances, which can be managed with continuous renal replacement therapy (CRRT) 3
• Hyperglycemic hyperosmolar state, which is diagnosed by elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status 4
• Acute renal failure, which requires special attention to issues of fluid balance and fluid overload 5
• Systemic weakness, which can be caused by various factors, including electrolyte abnormalities, and requires a well thought out approach to assessment and workup 6

Treatment Considerations

Treatment considerations for the patient include:

• Fluid resuscitation and correction of electrolyte abnormalities 4
• Monitoring of fluid status and electrolyte levels to avoid overcorrection or undercorrection 7
• Individualized and tailored dialysate and replacement fluid prescriptions for CRRT 3
• Close monitoring of electrolyte levels and adjustment of treatment as needed to prevent complications such as hypokalemia or hypophosphatemia 3