Soap Note Iron Deficiency Anemia

Name

Institution

Course

Tutor

Date

ID: Patient’s initials: K.L Age
: 29-years-OLD Gender: Female Ethnicity: African-American

SUBJECTIVE:

CC: “I am feeling weakness and increasingly becoming fatigued.”

History of Present Illness (HPI): K.L. is a 29-year-old African-American female patient who presents to the clinic complaining of increased fatigue and body weakness. She also admits to shortness of breath for the last few months. She reported to have noticed reduced exercise tolerance and frequent dizziness. The menstrual history reveals heavy and prolonged periods.

ASSESSMENT

1-.
Iron deficiency anemia (Main Diagnosis): The clinical symptoms of K.L., which include exhaustion, weakness, shortness of breath, decreased activity tolerance, and heavy menstrual periods, are consistent with iron deficiency anemia (IDA). Laboratory tests most commonly reveal low hemoglobin, ferritin, and mean corpuscular volume (MCV) levels (Stevenson et al., 2021). The primary diagnosis is based on the patient’s symptoms, demographics, and supportive lab data, all indicating a lack of iron for erythropoiesis. The prevalence of IDA among African-American women emphasizes its likelihood.

2-
Megaloblastic anemia: Megaloblastic anemia is suspected of symptoms such as weariness and dizziness. However, this diagnosis is less likely because K.L. lacks characteristic symptoms such as neurological problems or hypersegmented neutrophils (Hariz & Bhattacharya, 2019). Furthermore, IDA explains her significant menstrual bleeding better.

3
– Thalassemia: While thalassemia is possible, given her ethnic background, the lack of a family history and the predominance of IDA symptoms make it less likely (Kabootarizadeh et al., 2019). A specific set of symptoms and laboratory findings, such as abnormal hemoglobin electrophoresis, distinguishes thalassemia.

PLAN

1-Initiating the iron supplementation using the ferrous sulfate, 325 mg orally once daily. This is important in addressing the iron deficiency anemia (Nguyen & Tadi, 2020).

2-The dietary adjustments rich in iron, like lean meats, beans, and leafy beans. The approach helps in improving iron absorption (Avi, 2022).

3-The four-week follow-up appointment is arranged to help evaluate the patient’s response to treatment. Adjustment is made as needed, and iron levels (Kabootarizadeh et al., 2019).

Medications: 325 mg ferrous sulfate orally daily to manage iron deficiency anemia.

Patient Education

1- Educating the patient on the importance of constant iron supplementation to enhance therapy outcomes is critical. Maintaining a consistent intake ensures long-term iron deficiency correction, boosting the creation of healthy red blood cells (Hampl et al., 2023). This promotes increased energy levels, fatigue relief, and overall well-being, emphasizing the critical significance of patient adherence in treatment efficacy.

2- Instructing K.L. on dietary changes is critical for increasing iron levels. Iron-rich foods, such as lean meats, lentils, and leafy greens, should be included in her diet (Chouraqui, 2022). Emphasizing these dietary options and providing techniques to improve iron absorption offers a complete strategy for replenishing iron storage, bolstering supplementation effectiveness, and improving long-term hematologic health.

3- Providing information about probable adverse effects is critical to control patient expectations. Patient adherence must emphasize the need to continue to use despite these side effects (American Medical Association, 2023). Healthcare providers foster a patient-centered approach, supporting sustained adherence and favorable outcomes, by informing K.L. that side effects are often transient and that persistent use is essential to treatment success.

Referral:

Due to the complexity of anemia, particularly the considerable and protracted monthly bleeding that K.L. experienced, the patient is sent to a gynecological doctor for a full diagnosis and therapy. A gynecologist specializing in women’s reproductive health can perform a complete examination that involves a thorough physical examination, a detailed analysis of the patient’s menstrual history, and a deeper analysis of pertinent laboratory results (Shalowitz et al., 2021). A gynecologist should be consulted since heavy monthly bleeding can exacerbate iron deficiency anemia. This will ensure a comprehensive treatment plan that addresses underlying gynecological disorders and anemia.

Gynecologists can employ specialist diagnostic equipment and carry out necessary tests to pinpoint the precise reason for the severe bleeding, enabling targeted treatment strategies. Working with a gynecologist ensures that the patient gets the best care possible, addressing the current symptoms and underlying gynecological causes with long-term management plans for the best potential health outcomes.

Follow-Up:

K.L., a 29-year-old female with iron deficiency anemia, needs to schedule a follow-up

consultation in 4 weeks as part of her comprehensive healthcare management. This projected

return serves several important functions. First, it allows for a thorough evaluation of the treatment’s success and confirming that the prescribed ferrous sulfate supplementation is properly addressing the diagnosed deficiency. During this follow-up, iron levels are monitored using suitable laboratory tests, which aid in evaluating the therapy response and tailoring the following actions. Furthermore, the follow-up enables the earliest detection and mitigation of any emergent problems or side effects related to the prescription drug. This proactive approach is

consistent with patient-centered treatment, emphasizing the individual’s well-being and

experience. A 4-week follow-up meeting serves as a strategic checkpoint, allowing for continual

assessment, treatment plan revision, and individualized care to improve K.’s health outcomes.

References

American Medical Association. (2023, February 22).
8 reasons patients don’t take their medications. American Medical Association. https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications

Avi, V. (2022, November 30).
Megaloblastic anemia: Causes, symptoms, and treatment. Www.medicalnewstoday.com. https://www.medicalnewstoday.com/articles/megaloblastic-anemia

Chouraqui, J.-P. (2022). Dietary Approaches to Iron Deficiency Prevention in Childhood—A Critical Public Health Issue.
Nutrients,
14(8), 1604. https://doi.org/10.3390/nu14081604

Hampl, S. E., Hassink, S. G., Skinner, A. C., Armstrong, S. C., Barlow, S. E., Bolling, C. F., Avila Edwards, K. C., Eneli, I., Hamre, R., Joseph, M. M., Lunsford, D., Mendonca, E., Michalsky, M. P., Mirza, N., Ochoa, E. R., Sharifi, M., Staiano, A. E., Weedn, A. E., Flinn, S. K., & Lindros, J. (2023). Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity.
Pediatrics,
151(2). https://doi.org/10.1542/peds.2022-060640

Hariz, A., & Bhattacharya, P. T. (2019, January 23).
Megaloblastic Anemia. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537254/

Kabootarizadeh, L., Jamshidnezhad, A., Koohmareh, Z., & Ghamchili, A. (2019). Differential Diagnosis of Iron-Deficiency Anemia from beta-Thalassemia Trait Using an Intelligent Model in Comparison with Discriminant Indexes.
Acta Informatica Medica,
27(2), 78. https://doi.org/10.5455/aim.2019.27.78-84