CAR-SOAP

CASE STUDY 1 IRON DEFICIENCY ANEMIA

Case Study: Iron Deficiency Anemia Patient Information:

• Name: John Doe • Age: 35 • Gender: Male •

Occupation: Construction Worker •

Medical History: No significant medical history reported.

Presenting Complaint: John Doe presents to the clinic with complaints of fatigue,

weakness, and shortness of breath on exertion for the past few months. He reports feeling

unusually tired, even after a full night's sleep, and has noticed increased paleness of his skin and

conjunctiva.

Physical Examination Findings: • Vital Signs: BP 120/80 mmHg, HR 80 bpm, RR 16

breaths/min, Temp 98.6°F

• General: Pale skin and conjunctiva, fatigue apparent • Cardiovascular: Regular rhythm,

no murmurs or abnormal sounds • Respiratory: Clear lung fields bilaterally • Abdomen: Soft,

non-tender, no organomegaly • Neurological: Intact cranial nerves, normal motor and sensory

functions

Laboratory Investigations: • Hemoglobin (Hb): 9.5 g/dL (Normal range: 13.5-17.5 g/dL) •

Hematocrit (Hct): 29% (Normal range: 40-50%) • Mean Corpuscular Volume (MCV): 75 fL

(Normal range: 80-100 fL) • Serum Iron: 25 mcg/dL (Normal range: 60-170 mcg/dL) • Total Iron

Binding Capacity (TIBC): 400 mcg/dL (Normal range: 250-450 mcg/dL) • Ferritin: 10 ng/mL

(Normal range: 30-400 ng/mL)

Diagnosis: John Doe is diagnosed with iron deficiency anemia based on his clinical

presentation, physical examination findings, and laboratory results.

Questions for Students: 1. What are the common signs and symptoms of iron deficiency

anemia?

2. Explain the laboratory findings in John Doe's case and how they support the diagnosis

of iron deficiency anemia.

3. What are the potential causes of iron deficiency anemia in adults, and how would you

approach further investigations in this patient?

4. Discuss the treatment options for iron deficiency anemia, including dietary

recommendations and pharmacological interventions.

1. Iron deficiency anemia manifests in multiple symptoms. Fatigue, shortness of breath,

angina, and tachycardia are common symptoms of iron deficiency anemia (Kumar et al., 2022).

The reduced blood oxygen levels cause chest pains and tachycardia. One could also have

reduced intestinal blood flow due to the resultant hypoxemia, causing abdominal pain, weight

loss, and nausea (Kumar et al., 2022). Insufficient blood levels also result in brittle nails and pale

skin. Therefore, the symptoms the patient presented with, such as fatigue, shortness of breath,

pale skin, and chest exertion, suggest the condition.

2. The patient's blood components are off the normal levels. His hemoglobin is below the

normal range. Low hemoglobin levels are a significant indicator of iron deficiency anemia

(Kumar et al., 2022). The patient's hematocrit, ferritin, Mean Corpuscular Volume (MCV), and

serum iron levels are also low, suggesting iron deficiency anemia. However, the Total Iron

Binding Capacity is high, a condition common in iron deficiency anemia, due to

the body's increased attempt to transport iron. MCV is useful for differential diagnosis between

anemias because it determines the average size of the red blood cells.

3. Like the patient, iron deficiency anemia could result from multiple factors in

adults. First, iron is dependent on dietary intake (Kumar et al., 2022). Therefore, poor nutrition

and consuming foods low in iron are potential causes of the condition. Still, mensuration may

cause the condition. Menstruating women are thus a high-risk population for iron deficiency

anemia (Belali, 2022). In addition, digestive system problems, such as malabsorption, can cause

iron deficiency anemia when the body cannot absorb enough iron. Gastrointestinal conditions

like hemorrhoids and ulcers (capable of causing gastrointestinal bleeding) could also contribute

to iron deficiency anemia. Conversely, inquiring about the patient’s iron intake can help to

understand the contributions to his condition. Furthermore, a fecal occult blood test is important

because a positive result indicates bleeding somewhere in his gastrointestinal area. The chronic

bleeding produces anemia. This result leads to future gastroenterology reference (endoscopy and

CT scan).

4. Dietary changes to consume iron-rich foods are a primary part of the treatment for the

patient. A healthy diet constitutes about 1–5 mg of heme iron and 5 to 10mg of elemental iron

(Kumar et al., 2022). Foods with high iron content include leafy greens (broccoli, kale, brussels

sprouts) red pepper, beans, lentils, and lean meat including others. Fruits with elevated iron

content involve are fig, dates, raising, prunes, pomegranate, raspberries; moreover, fruits such as

kiwi, strawberries, oranges, lemon, grapefruit, blackcurrant, between others help with the

absorption of the iron because the high Vitamin C that it has. The treatment depends on the

etiology of the anemia and the patient response to his treatment. All the patients are individuals.

However, the patient should also take oral supplements of iron such as ferrous gluconate, sulfate,

fumarate and has the option of IM or IV injection. Also, it is very important to indicate to the

patient the side effects of the supplement iron such as dark stool, constipation, metallic taste,

upset stomach among others.

References

Belali, T. M. (2022). Iron deficiency anemia: prevalence and associated factors among residents

of northern Asir Region, Saudi Arabia. Scientific Reports, 12(1), 19170. https://

www.nature.com/articles/s41598-022-23969-1

Kumar, A., Sharma, E., Marley, A., Samaan, M. A., & Brookes, M. J. (2022). Iron deficiency

anemia: pathophysiology, assessment, practical management. BMJ open

gastroenterology, 9(1), e000759. https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC8744124/

You MUST use the Case Study #1 as the base of this SOAP NOTE #1