(Student Name)<\/strong> SOAP Note # ____ Name: [Redacted] Ferrous sulfate 325 mg PO daily<\/p>\n<\/li>\n Multivitamin<\/p>\n<\/li>\n<\/ul>\n PMH: Chronic iron-deficiency anemia, uterine fibroma Pap smear: Pending<\/p>\n<\/li>\n Mammogram: Pending<\/p>\n<\/li>\n Colonoscopy: Not indicated<\/p>\n<\/li>\n Lipid panel: Not performed<\/p>\n<\/li>\n A1C: Not performed<\/p>\n<\/li>\n STI screen: Not performed<\/p>\n<\/li>\n Depression screen (PHQ-9): Negative, 3\/27<\/p>\n<\/li>\n<\/ul>\n Surgical History: None reported Chief Complaint:<\/strong> \u201cI\u2019m here for follow-up of my anemia and fibroids; they are planning surgery.\u201d<\/p>\n Symptom analysis \/ HPI:<\/strong> Clinical Tools Used:<\/strong><\/p>\n PHQ-9: 3\/27<\/p>\n<\/li>\n GAD-7: 2\/21<\/p>\n<\/li>\n AUDIT-C \/ DAST: Negative<\/p>\n<\/li>\n<\/ul>\n Review of Systems (ROS):<\/strong> VITAL SIGNS:<\/strong> LABS \/ DIAGNOSTICS REVIEWED:<\/strong><\/p>\n CBC: Hgb 9.2 g\/dL, Hct 28%, MCV 70 fL<\/p>\n<\/li>\n Iron Studies: Ferritin 8 ng\/mL (low), Iron 25 \u00b5g\/dL (low), TIBC elevated<\/p>\n<\/li>\n Lipid Panel: Not performed<\/p>\n<\/li>\n A1C: Not performed<\/p>\n<\/li>\n EKG: Normal sinus rhythm<\/p>\n<\/li>\n Imaging: Pelvic ultrasound showing multiple uterine fibroids<\/p>\n<\/li>\n<\/ul>\n GENERAL APPEARANCE:<\/strong> Alert, oriented, no acute distress Red Flags \/ Reasons for Escalation:<\/strong><\/p>\n None noted<\/p>\n<\/li>\n Positive suicidal ideation<\/p>\n<\/li>\n Unstable vital signs<\/p>\n<\/li>\n Abnormal exam requiring urgent referral<\/p>\n<\/li>\n<\/ul>\n Clinical Note:<\/strong> Main Diagnosis:<\/strong> Differential Diagnoses:<\/strong> Labs and Diagnostic Tests to be Ordered:<\/strong><\/p>\n Repeat CBC in 4 weeks<\/p>\n<\/li>\n Iron studies in 4 weeks<\/p>\n<\/li>\n Pre-op labs per hematology and gynecology<\/p>\n<\/li>\n<\/ul>\n Pharmacological Treatment:<\/strong><\/p>\n Continue ferrous sulfate 325 mg PO daily with vitamin C for absorption<\/p>\n<\/li>\n Consider IV iron infusion if oral therapy insufficient before surgery<\/p>\n<\/li>\n<\/ul>\n Non-Pharmacological Treatment:<\/strong><\/p>\n Dietary counseling to increase iron-rich foods: lean red meat, beans, lentils, spinach<\/p>\n<\/li>\n Education on limiting tea\/coffee intake with meals to improve absorption<\/p>\n<\/li>\n<\/ul>\n Education:<\/strong><\/p>\n Explained importance of iron supplementation adherence to improve hemoglobin before surgery<\/p>\n<\/li>\n Reviewed signs of worsening anemia such as severe fatigue, shortness of breath, or chest pain and instructed to seek care if they develop<\/p>\n<\/li>\n Discussed nutrition and hydration strategies to manage heavy bleeding until surgery<\/p>\n<\/li>\n<\/ul>\n Follow-ups \/ Referrals:<\/strong><\/p>\n Follow-up with hematology for clearance<\/p>\n<\/li>\n Continue gynecology follow-up for hysterectomy scheduling<\/p>\n<\/li>\n Return to clinic in 4 weeks for lab review<\/p>\n<\/li>\n<\/ul>\n Visit Complexity \/ CPT Code:<\/strong> 99214 (Moderate complexity follow-up)<\/p>\n 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\u201312. https:\/\/doi.org\/10.1177\/1756284820938945<\/a><\/p>\n Munro, M. G., & Critchley, H. O. (2021). Uterine fibroids, abnormal uterine bleeding, and anemia. Best Practice & Research Clinical Obstetrics & Gynaecology, 74, 81\u201398. https:\/\/doi.org\/10.1016\/j.bpobgyn.2021.03.001<\/a><\/p>\n
Miami Regional University
Date of Encounter:
Preceptor\/Clinical Site:
Clinical Instructor:<\/p>\n
Main Diagnosis: Iron-Deficiency Anemia (D50.9)<\/p>\n
\nPATIENT INFORMATION<\/h3>\n
Age: 42
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: NKDA
Current Medications:<\/p>\n\n
Immunizations: Up to date per patient report
Preventive Care: Due for Pap smear, mammogram, and lipid panel
Preventive Screenings:<\/p>\n\n
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<\/p>\n
\nSUBJECTIVE DATA<\/h3>\n
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\u20139 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.<\/p>\n\n
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.<\/p>\n
\nOBJECTIVE DATA<\/h3>\n
BP: 118\/76 mmHg
HR: 88 bpm
RR: 16\/min
Temp: 98.2\u00b0F
O2 Sat: 98% RA<\/p>\n\n
NEUROLOGIC:<\/strong> No deficits noted
HEENT:<\/strong> Conjunctival pallor, oropharynx clear
CARDIOVASCULAR:<\/strong> Regular rate and rhythm, no murmurs
RESPIRATORY:<\/strong> Clear to auscultation bilaterally
GASTROINTESTINAL:<\/strong> Abdomen soft, non-tender, no hepatosplenomegaly
MUSCULOSKELETAL:<\/strong> Normal strength and tone, no edema
INTEGUMENTARY:<\/strong> Skin pale, no rashes or bruising<\/p>\n
\nASSESSMENT<\/h3>\n
\n
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.<\/p>\n
Iron-Deficiency Anemia (D50.9) (Johnson-Wimbley & Graham, 2020).<\/p>\n
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.<\/p>\n
\nPLAN<\/h3>\n
\n
\n
\n
\n
\n
\nReferences<\/h3>\n