| SOAP Note | Rationale |
Demographic Info: Baltimore, MD Age 27, Cauc, F Insurance: Kaiser Foundation Source: Family | Collecting demographic data is necessary for the provision of high-quality healthcare for all patients. It helps healthcare providers in identifying disparities in healthcare delivery for different populations. |
| SUBJECTIVE: | |
| CC: Dizziness and Headache | Diff Dx: Anaemia, Chronic Fatigue Syndrome, Hypoglycemia |
| HPI: A 27-year-old white female presents with dizziness for more than 1 month and frequent headaches for 1 month. Patient indicated that she felt generalized weakness and inability to perform simple household tasks. Patient indicates she has a normal menstruation cycle. Date of last menstruation was a week ago, indicates slight increase in period flow. Patient is not pregnant. | Recent menstrual flow, thus at risk for anemia (Wirth et al., 2017). Iron deficiency anemia – Women of reproductive age have been found to face high risks of developing anemia complications. As of 2011, about 496 million non-pregnant women were anemic (Wirth et al. 2017) |
| PMHx: Inflammatory bowel disease at age 19, treated with Anti-diarrheal medications, Calcium and vitamin D supplements, and Iron supplements. | Inflammatory bowel disease = IBD mainly attacks the gastrointestinal tract although other infections may attack organ systems (Eriksson et al., 2018). Anemia is an extraintestinal manifestation of IBD. |
| Fam Hx: Both Father and Mother are known. Mother recovered from cervical cancer. Sister is in perfect health. | Iron deficiency and tumor bleeding are common symptoms of anemia (Mozos, 2015). |
| Soc Hx: Works as an analyst, engaged, lives with her partner. Partner is a freelancer, spends a lot of time at home. Does not drink, denies drug use. | Patient has a relatively healthy lifestyle in a supportive environment. |
| Allergies: None | |
| Current Meds: NSAIDs (Aspirin, ibuprofen) | In some cases, NSAIDs can cause drug-inducedanemia when the body perceives the red blood cells as a threat (Cappellini et al., 2019). |
| ROS: | |
| General/Constitutional: Patient cites fatigue, weakness, headaches, jaundice and chest pain. | Common signs of Anemia but may vary in prevalence and magnitude of the disease. |
| HEENT: Loss of breath | Anemia reduces the number of hemoglobincarrying cells leading to a decrease in amount of oxygen in the body (Freeman et al. 2020). |
| Cardiovascular: Denies any heart issues and pain. | Specific types of iron deficiency anemia are associated with chronic heart failure, CHF and IBD (Cappellini et al. 2019). |
| Respiratory: wheezing and shortness of breath | Relatively low oxygen supply in body. |
| GU: Slight spotting in urine | Bleeding from gastrointestinal (GI), genitourinary (GU) is a common etiology of iron deficiency. |
| OBJECTIVE: | |
| VS: BP (sitting) 92/60, P 98, T 100.5, Weight127 lbs, height 70”, BMI 28.3, RBC – 1.9 cu.mm | Lower hemoglobin levels are associated with decrease in blood pressure (Mozos, 2015) |
| General Appearance: Not alert, distress | Increased fatigue disorients patient leading to loss in concentration. |
| Head: Headaches | Reduced supply of oxygen to the brain(Kaitha et al., 2015). |
| Eyes: No observed issues | Retinal hemorrhages associated with iron deficiency(Freeman et al., 2020). |
| Ears: Slight ringing in the ears | In anemic individuals, more blood is supplied to the jugular vein as it moves from the heart to brain. Causes ringing in middle ear(Freeman et al., 2020). |
| Nose/Sinuses: None | Cerebral venous thrombosis |
| Mouth: Tongue paleness | Low supply of blood to mouth leading to swelling and soreness. |
| Heart: No cardiovascular issues | Anemic deficiency correlated with chronic heart failure (Mozos, 2015). |
| Lungs: Shortness of breath | Increased respiratory rate is seen in trying to increase oxygen supply (Freeman et al., 2020). |
| Skin: Discoloration | Looking for pruritus signs. Increased itchiness, redness and bumps. |
| Laboratory & Diagnostic Testing: Complete blood counts (CBC). | RBC- 1.7 cu.mm (3.5-4.5 cu.mm), WBC- 1500 cells (4000-10000 cells), platelets – 55000 (1,500,000-4,500,000), Hb- 5.1 g/dl (12-16 g/dl), Hct- 13% (36%-46%), MCV- 104.1 fl (83-101 fl) |
| Red Cell Distribution Width | RDW- 30.2%.- check volume and size of RBCs |
| Total Iron-Binding Capacity (TIBC) | Folate- 55 mcg/dl (60-170 mcg/dl) - check quantity of iron in the body. |
| Peripheral smear | Macrocytic RBC, hypersegemented neutrophils, anisocytosis – check abnormalities in cell shape (Eriksson et al., 2018). |
| ASSESSMENT: | |
| Megaloblastic anemia | Large red blood cells observed on healthy cells. Low hemoglobin levels. Lower than 12.2 g/dl which is the minimum for women of all ages (Freeman et al., 2020). Certain NSAIDs cause bone marrow suppression and eventually anemia. |
| Chronic Fatigue Syndrome | Sleep disturbance, prominent fatigue, malaise and lack of concentration (Wirth et al., 2017). Orthostatic intolerance causes increased headaches, dizziness and nausea. CFS often associated with anemia. |
| Pregnancy complications | Patient mentioned she was not pregnant. Folate levels mustbe increased to minimize potential risks in case of future pregnancy (Jimenez et al., 2015). Potential issues include premature birth, stillbirth and death of the patient. |
| Cardiovascular complications | Arrhythmia. The heart pumps more blood to compensate for deficient oxygen levels in the blood (Mozos, 2015). With arrhythmia, heart enlarging is a risk that could increase morbidity rates. |
| PLAN: | |
| Obtain report of previous IBD | It is necessary to determine the extent of the IBD complications to identify any correlation between the anemia diagnosis and IBD. Patients with anemia are often found to have secondary chronic blood loss and low iron absorption rate caused by tissue inflammation (Kaitha et al. 2015) |
| Goals of Therapy | Replenish Vitamin B12, folate levels to increase hemoglobin levels. Increase patient working efficiency and minimize negative health outcomes (Jimenez et al., 2015). |
| Toxicity tests | Assess liver functioning due to past intake of NSAIDs such as aspirin and ibuprofen. Patient indicated that she purchased OTC drugs to reduce pain. |
15-20mg Ferrous Sulphate Vitamin C 500 units Single-dose of Albendazole 400mg | Smaller doses of ferrous sulfate are appropriate to reduce side effects (Jimenez et al., 2015). Vitamin C necessary for increasing absorption. Albendazole eliminates worms from bowel, which compete for Vitamin B12. |
| Diet and lifestyle changes | Patient must consult a dietitian to identify foods necessary for iron build up in the body. |
| COMMENTS: | |
| Patient is suffering from megaloblastic anemia caused by folate and Vitamin B12 deficiency. This leads to decrease in hemoglobin levels, subsequently reducing oxygen supply to tissues. The heart might pump more blood to make up for low oxygen. | Adverse effects may include organ failure and higher morbidity. |
| Lifestyle modification | Consume foods with folic acid, and reduce coffee and tea intake. |
References
Cappellini, M., Musallam, K., & Taher, A. (2019). Iron deficiency anemia revisited. Journal of Internal Medicine , 287(2), 153-170. https://doi.org/10.1111/joim.13004
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Eriksson, C., Henriksson, I., Brus, O., Zhulina, Y., Nyhlin, N., & Tysk, C. (2018). Incidence, prevalence and clinical outcome of anemia in inflammatory bowel disease: a population‐based cohort study. AP&T , 48(6), 638-645. https://doi.org/10.1111/apt.14920
Freeman, A., Rai, M., & Morando, D. (2020). Anemia Screening . StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499905/#_NBK499905_pubdet_
Jimenez, K., Dabsch, S. K., & Gasche, C. (2015). Management of Iron Deficiency Anemia. Gastroenterology & Hepatology , 11(4), 241–250. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4836595/pdf/GH-11-241.pdf
Kaitha, S., Bashir, M., & Ali, T. (2015). Iron deficiency anemia in inflammatory bowel disease. WJGP , 6(3), 62-72. https://doi.org/10.4291/wjgp.v6.i3.62
Mozos, I. (2015). Mechanisms Linking Red Blood Cell Disorders and Cardiovascular Diseases. BioMed Research International , 1-12. http://doi.org/10.1155/2015/682054
Wirth, J., Woodruff, B., Stone, R. E., Namaste, S., & Temple, V. (2017). Predictors of anemia in women of reproductive age: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. AJCN , 106(1), 416S–427S. https://doi.org/10.3945/ajcn.116.143073
