Create a SOAP NOTE on Anemia

MSN5700C Advanced Practice in Primary Care I

(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:

SOAP Note # ____
Main Diagnosis: Iron-Deficiency Anemia (D50.9)

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PATIENT INFORMATION

Name: [Redacted]
Age: 42
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: NKDA
Current Medications:

• Ferrous sulfate 325 mg PO daily

• Multivitamin

PMH: Chronic iron-deficiency anemia, uterine fibroma
Immunizations: Up to date per patient report
Preventive Care: Due for Pap smear, mammogram, and lipid panel
Preventive Screenings:

• Pap smear: Pending

• Mammogram: Pending

• Colonoscopy: Not indicated

• Lipid panel: Not performed

• A1C: Not performed

• STI screen: Not performed

• Depression screen (PHQ-9): Negative, 3/27

Surgical History: None reported
Family History: Mother with hypertension, father with type 2 diabetes
Social History: Lives with spouse and two children. Works part-time. Non-smoker. No alcohol or recreational drug use.
Sexual Orientation: Heterosexual
Nutrition History: Reports diet low in red meat and green leafy vegetables, limited protein intake due to preference

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SUBJECTIVE DATA

Chief Complaint: “I’m here for follow-up of my anemia and fibroids; they are planning surgery.”

Symptom analysis / HPI:
42-year-old Hispanic female presents for follow-up of chronic anemia secondary to abnormal uterine bleeding caused by fibroids. Reports ongoing heavy menstrual bleeding lasting 7–9 days with clot passage. Fatigue and generalized weakness are present, slightly improved with iron supplementation. She denies dizziness, chest pain, palpitations, or dyspnea at rest. No recent hospitalizations or transfusions.

Clinical Tools Used:

• PHQ-9: 3/27

• GAD-7: 2/21

• AUDIT-C / DAST: Negative

Review of Systems (ROS):
CONSTITUTIONAL: Pt states fatigue and weakness. Denies fever, chills, or weight loss.
NEUROLOGIC: Pt denies headaches, syncope, or numbness.
HEENT: Pt denies vision changes, epistaxis, or sore throat.
RESPIRATORY: Pt denies cough, wheezing, or shortness of breath.
CARDIOVASCULAR: Pt denies chest pain or palpitations.
GASTROINTESTINAL: Pt denies nausea, vomiting, or melena.
GENITOURINARY: Pt reports heavy menstrual bleeding with clots.
MUSCULOSKELETAL: Pt denies joint pain or swelling.
SKIN: Pt denies rash or lesions. Notes pale skin tone.

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OBJECTIVE DATA

VITAL SIGNS:
BP: 118/76 mmHg
HR: 88 bpm
RR: 16/min
Temp: 98.2°F
O2 Sat: 98% RA

LABS / DIAGNOSTICS REVIEWED:

• CBC: Hgb 9.2 g/dL, Hct 28%, MCV 70 fL

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• Iron Studies: Ferritin 8 ng/mL (low), Iron 25 µg/dL (low), TIBC elevated

• Lipid Panel: Not performed

• A1C: Not performed

• EKG: Normal sinus rhythm

• Imaging: Pelvic ultrasound showing multiple uterine fibroids

GENERAL APPEARANCE: Alert, oriented, no acute distress
NEUROLOGIC: No deficits noted
HEENT: Conjunctival pallor, oropharynx clear
CARDIOVASCULAR: Regular rate and rhythm, no murmurs
RESPIRATORY: Clear to auscultation bilaterally
GASTROINTESTINAL: Abdomen soft, non-tender, no hepatosplenomegaly
MUSCULOSKELETAL: Normal strength and tone, no edema
INTEGUMENTARY: Skin pale, no rashes or bruising

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ASSESSMENT

Red Flags / Reasons for Escalation:

• None noted

• Positive suicidal ideation

• Unstable vital signs

• Abnormal exam requiring urgent referral

Clinical Note:
Pt came to clinic for follow-up of chronic anemia related to abnormal uterine bleeding from fibroids. Reports fatigue and weakness. Labs confirm microcytic anemia with low hemoglobin and ferritin levels consistent with iron-deficiency anemia. Physical exam reveals conjunctival pallor and pale skin. No cardiac or respiratory compromise noted. Gynecology follow-up scheduled for hysterectomy after hematology clearance.

Main Diagnosis:
Iron-Deficiency Anemia (D50.9) (Johnson-Wimbley & Graham, 2020).

Differential Diagnoses:
I. Anemia of chronic disease: Considered due to chronic gynecologic condition, but iron studies show low ferritin and high TIBC, supporting iron deficiency rather than chronic disease.
II. Thalassemia trait: Microcytosis with anemia could indicate thalassemia, but patient lacks family history or ethnic background risk factors, and iron deficiency is more consistent with labs.
III. Hypothyroidism: Can present with fatigue and anemia, but thyroid history negative and no clinical hypothyroid features.

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PLAN

Labs and Diagnostic Tests to be Ordered:

• Repeat CBC in 4 weeks

• Iron studies in 4 weeks

• Pre-op labs per hematology and gynecology

Pharmacological Treatment:

• Continue ferrous sulfate 325 mg PO daily with vitamin C for absorption

• Consider IV iron infusion if oral therapy insufficient before surgery

Non-Pharmacological Treatment:

• Dietary counseling to increase iron-rich foods: lean red meat, beans, lentils, spinach

• Education on limiting tea/coffee intake with meals to improve absorption

Education:

• Explained importance of iron supplementation adherence to improve hemoglobin before surgery

• Reviewed signs of worsening anemia such as severe fatigue, shortness of breath, or chest pain and instructed to seek care if they develop

• Discussed nutrition and hydration strategies to manage heavy bleeding until surgery

Follow-ups / Referrals:

• Follow-up with hematology for clearance

• Continue gynecology follow-up for hysterectomy scheduling

• Return to clinic in 4 weeks for lab review

Visit Complexity / CPT Code: 99214 (Moderate complexity follow-up)

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References

Johnson-Wimbley, T. D., & Graham, D. Y. (2020). Diagnosis and management of iron deficiency anemia in the 21st century. Therapeutic Advances in Gastroenterology, 13, 1–12. https://doi.org/10.1177/1756284820938945

Munro, M. G., & Critchley, H. O. (2021). Uterine fibroids, abnormal uterine bleeding, and anemia. Best Practice & Research Clinical Obstetrics & Gynaecology, 74, 81–98. https://doi.org/10.1016/j.bpobgyn.2021.03.001

Peuranpää, P., Heliövaara-Peippo, S., & Fraser, I. (2022). Clinical management of heavy menstrual bleeding due to fibroids. Acta Obstetricia et Gynecologica Scandinavica, 101(2), 123–134. https://doi.org/10.1111/aogs.14277

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• Semester: Fall
• Course: MSN5700C Advanced Practice in Primary Care I
• Preceptor: Rural Visit: No
• Underserved Area/Population: Yes

Patient Demographics

• Age: 42 years
• Sex: Female
• Race: Hispanic
• Insurance: PPO
• Referral: No referral

Reason for Visit: Follow-up
Type of Decision-Making: Moderate
Chief Complaint: “I’m here for follow-up of my anemia and fibroids; they are planning surgery.”
Type of H & P: Follow-up visit

History of Present Illness (HPI):
A 42-year-old Hispanic female presents for follow-up of chronic anemia related to abnormal uterine bleeding secondary to uterine fibroma. She reports history of heavy, prolonged menstrual periods for over a year, associated with fatigue and weakness. She was previously diagnosed with uterine fibroids and is scheduled for hysterectomy once her hematologic status is optimized. She continues oral iron supplementation. Denies chest pain, palpitations, or shortness of breath at rest.

Past Medical History:

• Chronic iron-deficiency anemia
• Uterine fibroma

Medications:

• Ferrous sulfate 325 mg PO daily
• Multivitamin

Physical Exam (Pertinent):

• General: Alert, oriented, in no acute distress.
• Vitals: Stable.
• Cardiovascular: Regular rate and rhythm, no murmurs.
• Respiratory: Lungs clear bilaterally.
• Abdomen: Soft, non-tender, no masses palpated.
• Extremities: No edema.

Assessment/Plan:

1. Chronic Iron-Deficiency Anemia (D50.9): Continue iron supplementation, reinforce adherence, recheck CBC in 4 weeks.
2. Uterine Leiomyoma (D25.9): Candidate for hysterectomy; optimize preoperative status with hematology clearance.
3. Menorrhagia with Regular Cycle (N92.0): Symptom management until surgical intervention.

Plan: Continue oral iron, encourage iron-rich diet, follow-up labs (CBC, iron studies). Surgery planning coordinated with gynecology. Educated patient about importance of compliance with treatment to improve hemoglobin before procedure.

Social Problems Addressed:

• Growth & Development (reproductive health)
• Income/Economic (impact on work due to fatigue, planning for surgery)

Clinical Notes (Typhon text box):
Female patient with chronic anemia secondary to heavy menstrual bleeding caused by uterine fibroids. Currently managed with iron supplementation and scheduled for hysterectomy once hemoglobin is optimized. Patient reports improved energy with therapy, denies chest pain or SOB. Plan includes continued oral iron, dietary counseling, and repeat labs. Coordination with gynecology for surgical clearance.

ICD-10 Diagnosis Codes:

• D50.9 – Iron deficiency anemia, unspecified
• D25.9 – Leiomyoma of uterus, unspecified
• N92.0 – Excessive and frequent menstruation with regular cycle

CPT Codes (Billing/Labs):

• 85027 – CBC, automated
• 83540 – Iron studies
• 36415 – Venipuncture, routine