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Soap Note for Patient MA 23 Years old Saudi Female

Soap Note for Patient MA 23 Years old Saudi Female

Clinical Practicum 1

 (Advanced nursing practice – MSN)

Dr Siobhan Rothwell

Dublin City University

Riyadh 

Identification\ Problem Recognition

 Patient initial M.A Nationality Saudi Problem Statement
Age 23 Source of information Patient   Easy fatigability for few weeks and dizziness
Sex F Diagnosis Iron Deficiency Anemia

SUBJECTIVE DATA

 HPI  Patient M.A 23years old Saudi female who came to PHC clinic complaining of easy fatigability for the last few weeks and dizziness. The patient was well until 5 weeks ago when she noticed easy fatigability on carrying out normal activities. She thought it was due to lack of rest and took time off for 3days but the symptoms did not resolve. The patient has also noted that she cannot stand for long without feeling dizzy but has no episodes of losing consciousness in the current disease episode. She has not used any medication to relieve the symptoms. She also has not noted any aggravating factors.
PMH Patient M.A reports no history of any chronic conditions or genetic diseases.  The patient has not had any blood transfusions in the past.
Surgical History No previous surgical  reported
Family History -Mother: diabetes mellitus, hypertension for eight years now and arthritis diagnosed two years ago-Father: hypertension for the past ten years, stage three throat cancer

– 4 healthy siblings
Social History M.A   is in last year in college. She lives at home with her 4 young siblings and both parents. Patient denies exposure to drugs and smoking. Patient states she has been in the food diet for long time to maintain her healthy weight.  Patient goes to the gym 5 days in the week.
Allergies No known allergies for drugs, food or environment.
MEDS. Non
Immunization The patient immunization schedule is up-to date

ROS

 HEENT Patient denies any headache, fever, night sweats, hearing/vision changes, runny nose, sore throat and weight change. However patient reports dizziness and fatigue.
RESP. Patient denies for  any  cough, wheezing, shortness of breath and
CV Patient denies any chest pain, palpitations, exercise intolerance and edema.
GI\GU Denies no diarrhea, no nausea, no vomiting.
MSK denies no  muscle pains, joint pain, back pain
SKIN Patient denies any skin changes, rashes, nails changes but patient stated that   noticed her hair is become thin.
Mental Patient oriented to person and time. Denise  history of depression,  headaches and weakness

OBJECTIVE DATA

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PHYSICAL ASSESSMENT

 V\S T:37.3c        RR: 22 bpm       BP :110/74mmHgHT:161 cm    WT:55 kg            BMI:21.22
General Appearance She is alert and follows through to what is happening in the room. Well groomed and well nourished.
HEENT Hair: brown in color, noted thinning of the hair, it’s clean. Eyes: symmetrical, no redness, no tearing, the conjunctiva appears pale, sclera is white, the pupil reacts normally to the light, the eyelids close completely while blinking, there is a scar on the left eyebrow. Visual acuity normal. Mouth and throat: Mucous membranes appear dry and pale, oropharynx is clear, tonsils are pink, pharynx is normal, fresh breath, gums are pale, no bleeding, missing two lower incisors both central, tongue is pale. Spoon-shaped nails are noted. Soap Note for Patient MA 23 Years old Saudi Female
Neuro. Examination of all 12 cranial nerves was unremarkable,  patient able to maintain his gait and balance while pacing around the room
CV There is no finger clubbing noted. No edema of the lower limbs noted. Auscultation identifies regular rhythm without any murmur or gallops, or rubs. No tachycardia with exertion noted.
RESP. No signs of respiratory distress. Lung sounds are clear no rales, ronchi, or wheezes.
GI \ GU Not examined
Skin normal colour, texture , no lesions or eruptions noted
Musculoskeletal Not examined
Mental Alert and oriented, behaviour and speech appropriate, alert and cooperative to the examiner.

DIAGNOSTIC TESTS

 -complete blood count (CBC) and differential requestedThe result :

Test Item Value           Units Reference Rang Interpretation
CBC and Differential
Wbc 9.2            10^9/L 4-11 Normal
Hb 9.8 g/dL 12 – 15.5 Low
MCH 31.2 26.5 – 32.6 Normal
MCHC 34 32 – 36 Normal
RDW
Ferritin In Serum 11 13 – 150 Low
Iron (Fe) in Serum 44 50 – 170 low
RBCs 5.60 4,04-6.13 Normal
MCV 84 78-96 Normal
TIBC 494 µg/dL 250-460 High

DIFFRENTIAL DIAGNOSIS

 Diagnosis Positive findings Negative findings
Iron Deficiency Anemia Hb , Ferritin In Serum, Iron (Fe) in Serum were low and TIBC was highOn the Physical examination the onjunctiva was pale,  Spoon-shaped nails are noted
Thalassemia ruled out in the blood tests requested (MCV ,  MCHC  normal  Iron (Fe) in Serum low )
Sideroblastic anemia ruled out in the blood tests requested (TIBC was high )

Plan

 Nonpharmacological treatment Nutritional counseling for more balance diet recommended.
Pharmacological Treatment DRUG General Considerations
Ferrous sulphate 200mg  (one ) tablet three times per day for 3-6 months -until serum ferritin level exceeds 50 μg/L)- side effect includes nausea,constipation, heartburn, upper GI discomfort and  black stools

– medication taken half hour  before meals with ascorbic acid
Surgery/Other Procedures Not applicable
Follow Up Appointment given after 3 months
Education The patient educated on the appropriate diet including red meat, leafy vegetables, and the use of iron fortified cereals and flour.Educate the patient about iron supplements therapy

–       Take iron tablets with vitamin C to enhance its absorption(orange juice)

–       The side effects of iron supplements

–       Take iron tablets on an empty stomach

–        Multivitamins with calcium or dairy taken 2 hours after the iron supplement
Referral No need for referral in this case.  However Referral to a hematologist may consider if the nonadherence to or intolerance of oral iron replacement and if there is persistent microcytic anemia despite iron therapy and the ruling out of other causes.

Learning Resources Soap Note for Patient MA 23 Years old Saudi Female

 Buttaro, T., Trybulski, J., Polgar-Bailey, P. and Sandberg-Cook, J., (2016) (Primary Care. 5th ed. Mosby: ELSEVIER.Federico, J. R., Basehore, B. M., & Zito, P. M. (2019). Angular Chelitis. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK536929/

Harper, J. (2020). Iron Deficiency Anemia: Practice Essentials, Background, Pathophysiology. eMedicine. [online] Available at: https://emedicine.medscape.com/article/202333-overview.

Schutte, R., Huisman, H., Mels, C. M., Botha, S., Kruger, R., Smith, W., … & Schutte, A. E. (2019). Iron loading, alcohol and mortality: A prospective study. Clinical Nutrition, 38(3), 1262-1268.

Shim, J. Y., Kim, M. Y., Kim, Y. J., Lee, Y., Lee, J. J., Jun, J. K., … & Song, T. B. (2018). Efficacy and safety of ferric carboxymaltose versus ferrous sulfate for iron deficiency anemia during pregnancy: subgroup analysis of Korean women. BMC pregnancy and childbirth, 18(1), 1-8.