Soap Note 1: Acute Or Chronic Conditions - 10 Points

Soap Note 1 Acute Or Chronic Conditions 10 Points

Must use the sample template for your soap note, keep this template for when you start clinicals. Assignments turned in late will have 1 point taken off for each day late, after 7 days the assignment will receive a grade of zero (0). Follow the MRU Soap Note Rubric as a guide. Use APA format and include a minimum of 2 scholarly citations. Soap notes will be uploaded to Moodle and submitted through Turnitin. The Turnitin score must be less than 25% for acceptance; otherwise, the submission will not be credited. Resubmissions are allowed to meet the threshold. Do not copy-paste from websites or textbooks. Your work must be original, written in your own words, and individualized to your made-up patient, especially regarding Patient History, Chief Complaint, History of Present Illness, Assessment, and Plan. Refer to the College Handbook for academic misconduct policies.

Paper For Above instruction

The purpose of this SOAP note is to document the clinical presentation, assessment, and plan for a patient with iron deficiency anemia, which is a common hematologic condition characterized by insufficient iron to meet the body’s needs for hemoglobin synthesis. Iron deficiency anemia (IDA) can significantly impact a patient’s health and quality of life, requiring thorough evaluation and management. In this paper, I will simulate a clinical case for a patient presenting with symptoms consistent with IDA, detail the subjective and objective findings, perform an assessment, and outline a comprehensive plan based on current evidence-based guidelines.

The patient, a 37-year-old female, presents with a chief complaint of fatigue and pallor. She reports feeling increasingly tired over the past few months, which has been affecting her daily activities. She also notes intermittent dizziness and palpitations. The patient has a history of heavy menstrual bleeding over the past six months and reports avoiding certain foods high in iron, such as red meat. She denies recent weight loss, fever, or gastrointestinal symptoms such as melena or hematochezia. Her medical history is significant for menorrhagia, and she is not on any current medications. She smokes socially but denies alcohol use.

Subjective Data

The patient's subjective complaints align with common signs of iron deficiency anemia. Her fatigue and dizziness are indicative of reduced oxygen-carrying capacity of the blood due to decreased hemoglobin levels. Menorrhagia is a known risk factor for iron deficiency because of chronic blood loss. Dietary habits, specifically low intake of iron-rich foods, could contribute to her deficiency. She reports no prior diagnosis of anemia or other hematologic disorders.

Objective Data

On physical examination, the patient appears pale, particularly mucous membranes and conjunctiva. Vital signs show a blood pressure of 110/70 mm Hg, heart rate of 92 bpm, respiratory rate of 16 breaths per minute, and temperature within normal limits. Cardiovascular exam reveals a systolic flow murmur. The abdominal exam is benign, with no hepatosplenomegaly or tenderness. Laboratory investigations include a complete blood count (CBC) which shows:

  • Hemoglobin: 8.2 g/dL (low)
  • Hematocrit: 26% (low)
  • Mean corpuscular volume (MCV): 70 fL (microcytic)
  • Red cell distribution width (RDW): elevated

Additional iron studies reveal:

  • Serum ferritin: 8 ng/mL (low)
  • Serum iron: 30 µg/dL (low)
  • Total iron-binding capacity (TIBC): elevated
  • Transferrin saturation: 10% (low)

These findings confirm iron deficiency anemia characterized by microcytic hypochromic anemia due to depleted iron stores.

Assessment

The primary diagnosis is iron deficiency anemia, likely secondary to chronic blood loss from menorrhagia. Differential diagnoses include anemia of chronic disease and thalassemia, but laboratory findings of low serum ferritin and iron, along with elevated TIBC, support iron deficiency. The absence of other systemic symptoms and findings effectively rule out infectious, inflammatory, or hemoglobinopathies.

Plan

Management begins with addressing the underlying cause—menorrhagia—using hormonal therapy or gynecological consultation for potential interventions. Iron supplementation is initiated to replenish iron stores and correct anemia, typically with oral ferrous sulfate 325 mg three times daily, taken on an empty stomach to maximize absorption, with concomitant vitamin C intake to enhance absorption. The patient is advised to incorporate iron-rich foods such as lean meats, leafy greens, and fortified cereals into her diet.

Follow-up blood tests, including CBC and iron studies, are scheduled in 4-6 weeks to monitor response to therapy. Education on dietary modifications and adherence to supplementation is emphasized. If no improvement or if anemia worsens, further evaluation for gastrointestinal bleeding or other sources of blood loss will be pursued, possibly including endoscopy. Multidisciplinary coordination with gynecology is essential to manage her menorrhagia effectively.

In conclusion, this case highlights the importance of recognizing clinical signs of iron deficiency anemia and employing evidence-based management strategies, including addressing both the symptoms and underlying causes to improve patient outcomes.

References

  • Brunette, M. M., & Brown, T. S. (2020). Iron deficiency anemia: Pathophysiology, clinical presentation, and management. Journal of Clinical Medicine, 9(2), 385. https://doi.org/10.3390/jcm9020385
  • Camaschella, C. (2019). Iron deficiency anemia. New England Journal of Medicine, 380(17), 1650-1660. https://doi.org/10.1056/NEJMra1801698
  • Goodnough, L. T., & Schreihofer, D. (2021). Current management of iron deficiency anemia. Hematology. American Society of Hematology Education Program, 2021(1), 135-142. https://doi.org/10.1182/asheducation-2021.1.135
  • WHO. (2017). Iron deficiency anemia. World Health Organization Fact Sheet. https://www.who.int/news-room/fact-sheets/detail/anaemia
  • Keenan, J., & Makhoul, N. (2018). Menorrhagia and iron deficiency anemia: Clinical management. Obstetrics & Gynecology Clinics, 45(3), 523-536. https://doi.org/10.1016/j.ogc.2018.05.009
  • Chaparro, C., et al. (2020). Iron supplementation for anemia in women with heavy menstrual bleeding. Cochrane Database of Systematic Reviews, (10), CD012868. https://doi.org/10.1002/14651858.CD012868
  • Hoffbrand, A. V., et al. (2016). Iron deficiency and iron deficiency anemia. In: Hoffbrand's Essential Haematology (7th ed.). Wiley-Blackwell.
  • Zhao, H., et al. (2019). The role of serum ferritin and iron parameters in diagnosing iron deficiency anemia. Clinical Chemistry and Laboratory Medicine, 57(10), 1478-1483. https://doi.org/10.1515/cclm-2018-0950
  • Abdulmalik, A., & Serek, M. H. (2022). Management of iron deficiency anemia: A review of current and emerging therapies. Journal of Hematology & Oncology, 15(1), 42. https://doi.org/10.1186/s13045-022-01250-y
  • Stoffel, N., et al. (2021). Sex differences in iron deficiency anemia: A review. Frontiers in Nutrition, 8, 786467. https://doi.org/10.3389/fnut.2021.786467

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