Soap note

SOAP NOTE Name:  S.S Date: 10/10/2019 Time: 12:30 p.m   Age: 70 Sex: Female SUBJECTIVE CC:  “My skin is turning pale and my feet and hands feel cold”   HPI:  S.S comes to the clinic with complaints of her skin turning pale and feeling cold in the feet as well as the hands. The patient explains that she started having these symptoms three weeks ago. She mentions that the cold feeling in her feet and hands is accompanied by headache, chest pain, and dizziness, which go away after taking ibuprofen. She also mentions that she cannot walk for long distances because she feels short of breath and weak besides feeling exceedingly tired. She often rests to catch a breath. She also notes that even though she is vegetarian, she has been having an urge to consume dirt. The patient claims that she had been skipping meals recently since she was diagnosed with positive H. Pylori. She denies blood in stool, states that the last colonoscopy was in 2005 with normal results.

Medications: Ibuprofen PRN for headache and chest pain  Levothyroxine 0.50 mcg/daily for hypothyroidism PMH: Hypothyroidism diagnosed in 2013 Allergies:  NKD Medication Intolerances: None Hospitalizations/Surgeries: She mentions that in 2009, she underwent a breast biopsy for suspected breast cancer, but the results were negative. Colonoscopy 2005 negative results. Family History Father died 20 years ago from coronary artery disease. Mother died 15 years ago from diabetes. Brother was diagnosed with colon cancer 2 years ago. Other siblings are healthy. Social History Patient holds a Bachelor’s degree in commerce. Patient worked as a bank manager before retiring. Patient is married and lives with her husband (74 years of age) and two grandchildren (19 years and 15 years of age). Patient does not consume alcohol, smoke or abuse drugs. Patient mentions putting on her seatbelt on always.  ROS General Patient reports feeling extremely fatigued, dizzy, and feeling weak. Denies, night sweats, fever, chills, weight change

Cardiovascular Patient reports dyspnea and chest pain. Denies edema 

Skin Patient reports pale skin. Denies bruising,

Respiratory Patient reports dyspnea and wheezing. Denies

rashes, or lesions  cough, hemoptysis, hx of pneumonia or TB  Eyes Patient wears corrective lenses, reports blurring vision  

Gastrointestinal Denies abdominal pain, diarrhea, vomiting, nausea, or changes in stool color or bowel movement 

Ears Denies discharge, hearing loss, ear pain, ringing in ears

Genitourinary/Gynecological Denies burning, changes in color of urine, urgency, or frequency or vaginal discharge

Nose/Mouth/Throat Denies nose bleeds or discharge, dental disease, sinus problems, dysphagia, throat pain, hoarseness,  

Musculoskeletal Denies joint swelling, back pain, fracture hx, pain or stiffness, osteoporosis

Breast Denies SBE, bumps, tumors, or changes

Neurological Reports feeling weak. Denies paresthesias, syncope, black out spells, transient paralysis, seizures

Heme/Lymph/Endo Denies hx of blood transfusion, bruising, swollen glands, cold or heat intolerance, night sweats, increase hunger or thirst

Psychiatric Patient reports being anxious. Denies sleeping difficulties, depression, suicidal attempts/ideation

OBJECTIVE Weight    130 lbs       BMI 21.0 Temp 98.0 BP 123/62 Height 5’6 Pulse 105 Resp 17 General Appearance Well-nourished and well-developed, normal asthenic. Excellent attention to grooming Skin Skin is pale. Clear to lesion, rashes or ulcers HEENT Head is normocephalic/atraumatic without lesions; hair consistently dispersed. Eyes:  PERRLA. Scleral injection or Conjunctival absent. EOMs intact. Ears: Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Canals patent. Nose: Normal turbinates; nasal mucosa pink. Septal deviation absent. Neck: Supple. Full ROM; cervical lymphadenopathy and occipital nodes absent. Nodules or thyromegaly absent. Oral mucosa moist and pink. Non erythematous pharynx without exudate. Teeth are in excellent repair. Cardiovascular Regular RR. Gallops and rubs absent. JVD absent. 2+ peripheral pulses in both dorsalis and both radialis bilaterally Respiratory Lungs clear to auscultation and percussion bilaterally. Wheezes, rhonchi and crackles absent Gastrointestinal

Abdomen soft, non-tender, non-distended; BS active X4 quadrants. No hepatosplenomegaly Breast N/A Genitourinary N/A Musculoskeletal Unstable gait. Cyanosis, clubbing, pitting edema absent. Full motion range. Joint deformities absent Neurological Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both biceps and both knees. Psychiatric Excellent insight and judgment. Oriented X4. Excellent recent and remote memory. Appropriate affect and mood. Lab Tests Hemoglobin 9.8 g/dL (Low) Hematocrit 30.0 % (Low) Mean Corpuscular Volume (MCV): 65 fL (decreased) RDW 16.0% (increased) Platelet, Neutrophils, Mono, Eosinophils, basophils: WNL Serum ferritin levels: pending Serum iron- pending Reticulocyte count-pending Total iron binding capacity- pending

Special Tests None    Diagnosis Further test: Serum ferritin levels Serum iron Total iron binding capacity

Differential Diagnoses o 1-Iron Deficiency Anemia D50.9: o 2- Cold Autoimmune Hemolytic Anemia (AIHA) D59.1 o 3- Thalassemia D56.1 Diagnosis o Iron Deficiency Anemia (IDA) D50.9

Plan/Therapeutics Medication

 Ferrous sulfate 325 mg 1 tablet orally TID for 3 months  Vitamin C (500 units) q.d for 3 months

Education  Patient was educated on the significance of amplifying daily intake

of iron-rich foods  Patient was educated to increase vitamin C intake  Patient was advised to avoid drinking black tea.  Increase dietary fiber to prevent constipation, which is a side effects

of ferrous sulfate Follow-up

 Patient scheduled for a follow-up appointment in 4 weeks, to repeat blood work after therapy. Patient was advised to contact the clinic if symptoms exacerbate or do not improve

Referral  GI for colonoscopy

Discussion of Assessment and Plan S.S is a 70 y/o Caucasian female with complaints of pale skin and cold in the feet

and hands. Based on the patient's symptoms, physical exam, and diagnostic findings, the primary diagnosis is iron deficiency anemia (IDA) D50.9. IDA is the most prevalent type anemia, where there is an inadequate number of healthy blood cells (Camaschella, 2015). As the name suggests, the condition occurs because of insufficient iron. Without sufficient iron, the body is not able to produce adequate hemoglobin (Camaschella, 2015). The disease is characterized by symptoms including fatigue, shortness of breath, cold feet and hands, chest pain, fast heartbeat, and strange cravings for non-nutritive substances, including starch, dirt, or ice (Alzaheb & Al-Amer, 2017). Risk factors include being female and being vegetarian (Alzaheb & Al-Amer, 2017). The condition was confirmed by a low level of hemoglobin and a low RBC volume as established by the CBC test. According to Hennek et al. (2016), patients with IDA exhibit low levels of hemoglobin than average (12.0-15.5 g/dL in females) and a volume of RBC lower than average (80- 96 fL/red cell in adults).

Other conditions that may present with similar symptoms include Cold Autoimmune Hemolytic Anemia (AIHA) D59.1 and Thalassemia D56.1. Cold AIHA was ruled out due to the absence of critical symptoms such as pain in the back of the legs, diarrhea, and pain and blue coloring in the feet and hands, which are common in individuals with the condition (Barcellini, 2015). Additionally, the patient does not present with key risk factors associated with cold AIHA. Such include infections, certain cancers, collagen-vascular diseases such as systemic lupus erythematosus, and family history of the hemolytic disease (Barcellini, 2015). Nevertheless, confirmation of the absence of cold AIHA will be possible once the Coombs test results are established, which should be negative for antibodies, which may affect RBCs (Khan et al., 2017). Thalassemia was ruled out because the patient does not present with crucial features associated with the condition, including dark urine, facial bone deformities, abdominal swelling, and yellowish skin (Origa, 2017). Furthermore, the condition is common in individuals of Italian, Greek, Asian, African, or Middle Eastern descent (Origa, 2017). The patient is Caucasian.

The patient's treatment included iron supplements, and vitamin C. Evidence has demonstrated that a dosage of 120 mg of elemental iron once daily can replenish iron in the body in three months (Okam, Koch, & Tran, 2016). Moreover, vitamin C is excellent

in promoting the absorption of iron when taken with iron pills once each day (Fei, 2015). Patient education included increasing iron and vitamin C intake and avoiding the

consumption of black tea. Notably, the patient is vegetarian, which puts her at risk of iron deficiency. Increasing the intake of foods rich in iron such as beans, cashews, fortified breakfast cereals, baked potatoes, and whole-grain and enriched breads can assist in raising her iron levels (Schrier et al., 2016). Moreover, the patient was also educated on the significance of increasing her vitamin C intake. Citrus fruits, papaya, strawberries, and cantaloupe are rich sources of vitamin C, which can promote the absorption of iron in the body (Fei, 2015). However, the patient was also educated to avoid the consumption of black tea as it lessens the absorption of iron (Ahmad Fuzi et al., 2017). Follow-up was scheduled in four weeks, and the patient was advised to contact the clinic if symptoms exacerbate or fail to improve with therapy.

EVALUATION OF THE ENCOUNTER: The encounter with the patient went exceedingly well. Specifically, assessment, diagnosis, as well as treatment went as needed. The patient cooperated all through and was ready to adhere to the treatment plan. We had a serious discussion concerning increasing iron and vitamin C intake and she was given a list of food products, which are rich in the nutrients. I believe that all the required history together with assessment data was gathered and nothing was left out.

Reference: Ahmad Fuzi, S. F., Koller, D., Bruggraber, S., Pereira, D. I., Dainty, J. R., & Mushtaq, S. (2017).

A 1-h time interval between a meal containing iron and consumption of tea attenuates the inhibitory effects on iron absorption: a controlled trial in a cohort of healthy UK women using a stable iron isotope. The American journal of clinical nutrition, 106(6), 1413- 1421.

Alzaheb, R. A., & Al-Amer, O. (2017). The prevalence of iron deficiency anemia and its associated risk factors among a sample of female university students in Tabuk, Saudi Arabia. Clinical Medicine Insights: Women's Health, 10, 1179562X17745088.

Barcellini, W. (2015). New insights in the pathogenesis of autoimmune hemolytic anemia. Transfusion medicine and hemotherapy, 42(5), 287-293.

Camaschella, C. (2015). Iron-deficiency anemia. New England journal of medicine, 372(19), 1832-1843.

Fei, C. (2015). Iron Deficiency Anemia: A Guide to Oral Iron Supplements. Clinical Corelation The nyu langone online journal of medicine https://www clinicalcorrelations org.

Hennek, J. W., Kumar, A. A., Wiltschko, A. B., Patton, M. R., Lee, S. Y. R., Brugnara, C., ... & Whitesides, G. M. (2016). Diagnosis of iron deficiency anemia using density-based fractionation of red blood cells. Lab on a Chip, 16(20), 3929-3939.

Khan, U., Ali, F., Khurram, M. S., Zaka, A., & Hadid, T. (2017). Immunotherapy-associated autoimmune hemolytic anemia. Journal for immunotherapy of cancer, 5(1), 15.

Liebman, H. A., & Weitz, I. C. (2017). Autoimmune hemolytic anemia. The Medical clinics of North America, 101(2), 351-359.

Okam, M. M., Koch, T. A., & Tran, M. H. (2016). Iron deficiency anemia treatment response to oral iron therapy: a pooled analysis of five randomized controlled trials. Haematologica, 101(1), e6.

Origa, R. (2017). β-Thalassemia. Genetics in Medicine, 19(6), 609.

Schrier, S. L., Auerbach, M., Mentzer, W. C., & Tirnauer, J. S. (2016). Treatment of iron deficiency anemia in adults. UpToDate. Waltham (MA): Wolters Kluwer.