Finish the case with a paragraph justifying a theoretical perspective

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 Finish the case with a paragraph justifying a theoretical perspective supporting your management approach.

SOAP NOTE

Name: S.S

Date:

Time: 12:30 p.m

Age: 68

Sex: Female

SUBJECTIVE

CC:

My skin is turning pale, and my feet and hands are cold. I’m also exhausted.”

HPI:

S.S. complains of her skin turning pale and feeling cold in her feet and hands when she visits the clinic. The patient claims that she has been experiencing these symptoms for three weeks. She says the icy sensation in her feet and hands is accompanied by headaches, chest pain, and dizziness, all of which subside after taking ibuprofen. She also claims that she is unable to walk long distances because she is out of breath and weak, in addition to being exhausted. She takes frequent breaks to gather her breath. She also mentions that, despite being a vegetarian, she has had an inclination to eat dirt. Since being diagnosed with positive HBV, the patient reports she has been avoiding meals. Pylori.

She denies blood in stool, states that the last colonoscopy was in 2010 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 2010 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 paresthesia, 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 turbinate’s; 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

Diagnosis


Iron Deficiency Anemia (IDA) D50.9:
The primary diagnosis is iron deficiency anemia (IDA) D50.9, judging from the victims’ signs, physical results, and diagnostic findings. IDA is characterized by a lack of enough iron in the body; there exists little hemoglobin in the patients’ blood (Mantadakis et al., 2020). Hemoglobin plays an essential role in moving oxygen in the body. For hemoglobin to be formed, it requires various nutrients like iron, vitamins, and proteins. The signs and symptoms present in the disease include difficulty in breathing, getting exhausted quickly, tongue burn, cracks in the skin of the mouth, cold feet and hands, strange cravings, and several others. Hemoglobin and hematocrit that show levels of red blood cells indicated low levels in the lab test hence confirming the condition of IDA. S.S results gave 9.8 g/dL hemoglobin and 30% hematocrit, which are below the standard average of 12.0-15.5 g/dL in females and 80-96 fL red cells, respectively.

Differential Diagnoses

Cold Autoimmune Hemolytic Anemia (AIHA) D59.1Cold AIHA was the second possible disease characterized by dark urine, jaundice, chest pains, headaches, cold hands and feet, diarrhea, etc. The patient never presented the major symptoms of Cold AIHA; therefore, the condition was eliminated. Furthermore, the victim does not experience major risk aspects of Cold AIHA like family history of hemolytic disorders, particular cancers, or collagen-vascular infections. But once Coombs test findings are established negative for antibodies, there will be confirmation of lack of Cold AIHA. (Murakhovskaya, 2020).

Thalassemia D56.1: The primary symptoms of Thalassemia include weakness, slow growth, yellowish skin, abdominal swelling, dark urine, and facial bone disorders (Jyothshna & Kumar, 2018). Thalassemia was eliminated since the patient never presented the significant symptoms of the condition. Furthermore, people from Italy, Greek, Africa, or Middle Eastern descent face increased risk factors for the condition, yet the patient is Caucasian.

Gastritis K29. 70: Gastritis is a general term for a group of conditions with one thing in common: Inflammation of the lining of the stomach. The inflammation of gastritis is most often the result of infection with the same bacterium that causes most stomach ulcers or the regular use of certain pain relievers. ( Lenti, & Di Sabatino, A. (2020).

Plan/Therapeutics

General measures

· Search for underlying cause and correct.

· Avoid transfusions, except in rare cases.

Medication

Ferrous sulfate 325 mg TID, ferrous gluconate 300 mg 1 to 3 tablets BID–TID or on an empty stomach 1 hour before meals

· Vitamin C (500 units) qd 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

Postmenopausal women with IDA (Test for colon cancer.)

References

Firquet, A., Kirschner, W., & Bitzer, J. (2018). Forty to fifty-five-year-old women and iron deficiency: clinical considerations and quality of life. Gynecological Endocrinology33(7), 503-509.

Hill, A., Wendt, S., Benstoem, C., Neubauer, C., Meybohm, P., Langlois, P., … & Stoppe, C. (2018). Vitamin C to improve organ dysfunction in cardiac surgery patients—Review and pragmatic approach. Nutrients10(8), 974.

Jyothshna, P., & Kumar, A. B. (2018). Awareness on thalasemia prevention and its treatment in community practice-a brief review. Jyothshna Al. World J. Pharm. Res.6, 280.

Lenti, M. V., Rugge, M., Lahner, E., Miceli, E., Toh, B. H., Genta, R. M., … & Di Sabatino, A. (2020). Autoimmune gastritis. Nature Reviews Disease Primers6(1), 1-19.

Mantadakis, E., Chatzimichael, E., & Zikidou, P. (2020). Iron deficiency anemia in children residing in high and low-income countries: risk factors, prevention, diagnosis and therapy. Mediterranean Journal of Hematology and Infectious Diseases12(1).

Man, Y., Xu, T., Adhikari, B., Zhou, C., Wang, Y., & Wang, B. (2021). Iron supplementation and iron-fortified foods: a review. Critical Reviews in Food Science and Nutrition, 1-22.

Murakhovskaya, I. (2020). Rituximab use in warm and cold autoimmune hemolytic anemia. Journal of Clinical Medicine9(12), 4034.

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