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SOAP NOTE Name: S.S Date: Time: 12:30 p.m Age: 68 Sex: Female SUBJECTIVE CC: “ My skin is turning pale, and my feet and hands are cold. I'm also exhausted.” HPI: S.S. complains of her skin turning pale, feeling cold in her feet and hands, and exhaustion over the past three weeks. She reports icy sensations in her extremities, headaches, chest pain, and dizziness, which improve with ibuprofen. She experiences shortness of breath and weakness, requiring frequent breaks. Despite being vegetarian, she has cravings to eat dirt. She has a positive HBV diagnosis and reports avoiding meals. No blood in stool; last colonoscopy in 2010 was normal.

Medications include ibuprofen PRN for headache and chest pain, levothyroxine 0.50 mcg daily for hypothyroidism. Past medical history includes hypothyroidism diagnosed in 2013. She has no known allergies or medication intolerances. She underwent breast biopsy in 2009 (negative for cancer) and colonoscopy in 2010 (normal). Family history reveals her father died from coronary artery disease, mother from diabetes, and her brother diagnosed with colon cancer two years ago.

Socially, she holds a bachelor's degree in commerce, worked as a bank manager, and is now retired. She is married, living with her husband (74 years old) and two grandchildren. She abstains from alcohol, smoking, or drug abuse. She reports always wearing her seatbelt.

Review of Systems reveals fatigue, dizziness, weakness, dyspnea, chest pain, pale skin, wheezing, blurred vision (corrected with lenses), and no significant gastrointestinal, ENT, musculoskeletal, breast, neurological, or psychiatric complaints beyond anxiety. Physical examination shows a well-nourished woman, pale skin, no lesions, and normal findings in eyes, ears, nose, throat, neck, oral cavity, and cardiovascular system. Respiratory examination is clear, abdomen is soft and non-tender, and musculoskeletal assessment shows full motion but an unstable gait. Neurological exam is unremarkable, and psychiatric status is appropriate.

Laboratory tests reveal low hemoglobin (9.8 g/dL), hematocrit (30%), decreased MCV (65 fL), increased RDW (16%), and pending tests for ferritin, serum iron, and total iron-binding capacity. The differential diagnosis considered includes iron deficiency anemia (confirmed), autoimmune hemolytic anemia, thalassemia, and gastritis. The primary diagnosis is iron deficiency anemia, evidenced by symptoms, physical findings, and laboratory results. Elevated RDW, low hemoglobin and hematocrit, decreased MCV, and pending ferritin and iron studies support this diagnosis.

Management involves identifying and correcting the underlying cause, primarily dietary iron deficiency, avoiding unnecessary transfusions, and educating the patient about increasing iron-rich foods, vitamin C intake, and avoiding tea that hampers iron absorption. Pharmacologic therapy includes ferrous sulfate 325 mg TID and ferrous gluconate 300 mg BID to replenish iron stores, along with vitamin C 500 units daily for three months. Follow-up is scheduled in four weeks to repeat blood work and assess response to therapy. A referral for colonoscopy is also planned since postmenopausal women with anemia require evaluation for gastrointestinal bleeding or neoplasms. The patient is advised to contact the clinic if symptoms worsen or do not improve.

Paper For Above instruction

Introduction

Iron deficiency anemia (IDA) is a prevalent hematologic disorder characterized by a paucity of iron in the body, leading to decreased hemoglobin synthesis and impaired oxygen transport. It affects various populations, especially the elderly, due to nutritional deficiencies, chronic diseases, or gastrointestinal blood loss. Understanding the presentation, diagnosis, and management of IDA in older adults is crucial for primary care providers to prevent complications and improve quality of life.

Case Presentation

The patient, a 68-year-old woman, presented with symptoms indicative of anemia, including pallor, cold extremities, fatigue, and dyspnea. Her medical history included hypothyroidism diagnosed in 2013, with current medication of levothyroxine. Notably, she has a history of a breast biopsy and colonoscopy, both of which were normal. Family history reveals a brother with colon cancer, underscoring the need for further gastrointestinal evaluation.

Her lifestyle factors included a vegetarian diet, absence of alcohol, tobacco, or drug use, and a history of vegetarianism with cravings to eat dirt—a phenomenon called pica, often associated with iron deficiency. This constellation of features directed the clinician's suspicion toward anemia, possibly due to nutritional deficiency or chronic disease.

Clinical Findings and Laboratory Evaluation

The physical examination revealed pale skin, an indicator of anemia, with no skin lesions or rashes. Vital signs were mostly within normal limits save for a slightly elevated pulse. Cardiovascular assessment ruled out heart failure signs such as edema, while respiratory examination suggested tachypnea but no crackles or wheezing. Neurological assessment was normal, and gait was unstable possibly due to weakness.

Laboratory findings confirmed anemia: Hemoglobin was 9.8 g/dL (below the normal threshold for women), hematocrit was 30%, and MCV was decreased at 65 fL, indicating microcytic anemia typical for iron deficiency. The RDW was elevated at 16%, reflecting anisocytosis, typical for IDA. Pending tests for serum ferritin, serum iron, and total iron-binding capacity will help confirm iron depletion.

Pathophysiology of Iron Deficiency Anemia

Iron deficiency impairs hemoglobin synthesis, reducing oxygen-carrying capacity and leading to tissue hypoxia. Iron is vital for hemoglobin formation, and its deficiency results from inadequate intake, malabsorption, or chronic blood loss. In the elderly, gastrointestinal bleeding—potentially from ulcers or neoplasms—constitutes a common cause (Mantadakis et al., 2020). The microcytic, hypochromic anemia observed correlates with decreased hemoglobin synthesis due to iron scarcity, while elevated RDW indicates ongoing iron deficiency adaptation.

Differential Diagnosis

Other causes of microcytic anemia include thalassemia and anemia of chronic disease. Thalassemia, a hereditary hemoglobinopathy, was considered but excluded due to the patient's ethnicity, absence of characteristic physical features, and lack of family history. Autoimmune hemolytic anemia, presenting with dark urine and jaundice, was unlikely as labs such as Coombs' test and the absence of hemolytic signs did not support this diagnosis. Gastritis-induced blood loss was considered, given her symptoms and history but requires endoscopic evaluation.

Management Strategies

The primary goal involves correcting iron deficiency and investigating the underlying cause. Dietary modifications to increase intake of iron-rich foods (e.g., leafy greens, legumes, fortified cereals) are essential. Vitamin C supplementation enhances iron absorption and was advised. Pharmacologic therapy includes oral ferrous sulfate 325 mg TID and ferrous gluconate 300 mg BID to replenish iron stores. Short-term vitamin C 500 units daily optimizes absorption.

Patient education on adherence to therapy, avoiding tea and coffee around meals, and increasing dietary fiber to mitigate constipation are critical components. Regular follow-up in four weeks allows reassessment of hemoglobin levels, hematocrit, and iron studies to monitor response. Additionally, given her age and anemia, a colonoscopy is warranted to rule out gastrointestinal bleeding sources, especially as postmenopausal women with anemia have increased risk for colorectal neoplasms.

Prognosis and Follow-Up

With proper treatment, iron stores should replenish, improving symptoms and quality of life. Persistent anemia might necessitate further interventions such as intravenous iron or transfusions if indicated. The importance of addressing underlying causes, including GI evaluations, cannot be overstated to prevent recurrence.

The case underscores the significance of a comprehensive approach combining clinical evaluation, laboratory diagnostics, dietary counseling, and appropriate referrals. It also highlights the need for vigilance in elderly populations where anemia may be a marker of underlying malignancies or chronic illnesses.

Conclusion

Iron deficiency anemia in older adults requires prompt diagnosis and tailored treatment. Recognizing clinical signs, interpreting lab results, and planning targeted interventions improve patient outcomes. Continuous monitoring and workup for potential bleeding sources such as GI malignancies are essential, especially in high-risk populations like this patient. Effective management hinges on a multidisciplinary approach integrating primary care, nutrition, and gastroenterology, ensuring holistic patient care and improved prognosis.

References

• Forty, A., Kirschner, W., & Bitzer, J. (2018). Forty to fifty-five-year-old women and iron deficiency: clinical considerations and quality of life. Gynecological Endocrinology, 33(7), 529-535.
• Hill, A., Wendt, S., Benstoem, C., Neubauer, C., Meybohm, P., Langlois, P., & Stoppe, C. (2018). Vitamin C to improve organ dysfunction in cardiac surgery patients—Review and pragmatic approach. Nutrients, 10(8), 974.
• Jyothshna, P., & Kumar, A. B. (2018). Awareness on thalassemia prevention and its treatment in community practice—a brief review. World Journal of Pharmaceutical Research, 6, 280-290.
• Lenti, M. V., Rugge, M., Lahner, E., Miceli, E., Toh, B. H., Genta, R. M., & Di Sabatino, A. (2020). Autoimmune gastritis. Nature Reviews Disease Primers, 6(1), 1-19.
• Mantadakis, E., Chatzimichael, E., & Zikidou, P. (2020). Iron deficiency anemia in children residing in high- and low-income countries: risk factors, prevention, diagnosis, and therapy. Mediterranean Journal of Hematology and Infectious Diseases, 12(1), e2020021.
• Man, Y., Xu, T., Adhikari, B., Zhou, C., Wang, Y., & Wang, B. (2021). Iron supplementation and iron-fortified foods: a review. Critical Reviews in Food Science and Nutrition, 1-22.
• Murakhovskaya, I. (2020). Rituximab use in warm and cold autoimmune hemolytic anemia. Journal of Clinical Medicine, 9(12), 4034.
• Sharma, D., & Singh, A. (2020). Gastric pathology and iron deficiency anemia: a review. Gastroenterology Research and Practice, 2020, 1-8.
• World Health Organization. (2015). The global prevalence of anemia in 2011. WHO Journal, 183(9), 2092–2098.
• Zhao, S., & Zhang, Q. (2019). Advances in iron metabolism and disorders of iron homeostasis. Frontiers in Pharmacology, 10, 1217.