BRIEF HISTORY This pleasant 55 year old male presented to his family doctor with symptoms of loss of sexual drive and a
reduction in the size of his testes. He appears to have an abnormal bronze skin color Laboratory findings
Included mildly abnormal liver tests (AST, alkaline phosphatase), elevated plasma iron level with greater than
50% saturation of the transferrin, and an elevated serum ferrion. The liver biopsy showed extensive iron
deposition in hepatocytes and in bile ducts. The hepatic iron index was greater than 1.9. Studies confirm
hemochromatosis, and venesection was strongly recommended The veneseation procedure was explained to
the patient. He understands that he will require weekly phlebotomy for about 1 or 2 years. After that, it will be
performed at intervals as required to maintain levels within the normal range He agreed and signed the content
form
PROCEDURE
The patient was here today for his 1st treatment. He states he does not have any questions at this time and was
ready to begin treatments. Using sterte technique, his first phlebotomy session with 500 ml of blood (about 250
mg of iron) was performed Following the procedure, the site was negatrve for abnormal bleeding or hematoma.
Sterile gauze secured with tape was placed over the puncture site. Since there were no complications or
abnormalities, the patient was discharged and driven home by his very supportive wife.
ICD-10 CM
CPR