What are the common signs and symptoms of iron deficiency anemia?
Soap Note 1 is based on the Case Study # 1 ATTACHED.
You MUST use the Case Study #1 ATTACHED as the base of this SOAP NOTE #1
Must use the sample template ATTACHED for THE soap note,
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include minimum of 2 Scholarly Citations.
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DUE DATE MARCH 26, 2025
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
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PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
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PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
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Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
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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.
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