SOAP Note: Anemia in Pregnancy

Name: PC

 Sex: Female

Age: 27 years old

Date: 17/7/2015

SUBJECTIVE

CC:  “I feel weak, and my breath is going away.”

HPI:  PC has a pregnancy ofis 30 weeks pregnant. She had not experienced any complications until eight days ago when she started feeling weak. Her hands became cold, and she could feel some coolness in her feet. Five days ago, PC developed shortness of breath, and she experienced dizziness and light-headedness. Her symptoms have persisted until now, and she has come with her partner for treatment. They both confirm that they have been using a condom as a birth control measure and as a strategy to prevent transmission of any STDs. They both have never had any STDs, and this pregnancy is the first one since they got married two years ago. Further, the two are sexually active, and none of them confirms to have suffered from any STDs. Independent interview reveals that no partner has had other sexual partners. They both confirm that they need further information on whether sexual intercourse during pregnancy, and they need to understand whether it is safe for the baby.

Sexual History

Partner: Sexually active. Only with the husband in the past 12 months.

Practices: Denies other sexual encounters.

Protection: None, but used condoms occasionally before pregnancy.

Past Hx of STDs: No history of STDs.

Prevention of Pregnancy: Condoms, but currently pregnant.

Other concerns: Expresses nNone.

The patient explains HPI as follows:

O- Eight days ago.

L- The whole body.

D- Constant.

C- Dull.

A- Any physical activity aggravates the symptoms.

R- Resting relieves fatigue.

T-She experiences the symptoms all the time.

T-Currently not on any treatment.

S-Rates symptoms 5/10.

Medications: Not using drugs now but takes prenatal vitamins. She stopped taking daily folic acid four weeks ago because she could “feel like vomiting.”

PMH

Allergies:  None towards medications, food, or latex.

Drug Intolerances: Currently none.

Traumas/Chronic Illness: None.

Surgeries and Admissions: None.

Family History: Her father and mother are all alive without any illness. All her four siblings are alive and well. She has no information regarding about chronic diseases of on about her grandparents.

Social History: She is married and lives with her husband. Both are teachers. She does not use any illicit drugs, alcohol, or cigarettes. No prescribed diet.

ROS

General: Positive for fatigue and a headache. Denies ecchymoses or fever.

Cardiovascular: Positive for chest pain and palpitations. Denies syncope or claudication.

Skin: Positive for cold skin. Denies any growths, rashes, or any change of the color of the skin.

Respiratory: Positive for shortness of breath and chest pain. Denies a cough, hemoptysis, or wheezing.

Eyes: Denies vision problems or eye pain.

Gastrointestinal: Positive for loss of appetite that started ten days ago. Denies production of hard stools, frequent passage of gas, bloating, diarrhea, nausea, or dysphagia.

Ears: Denies hearing abnormalities or tinnitus.

Genitourinary: Does SBE weekly. Fundal height is 36 weeks. Menarche at 12 years with a 28-day irregular cycle. No swellings or lesions on the vulva. Last pap six months ago. No mammogram has ever been done. Denies stress incontinence.

Nose/Mouth/Throat: Denies sinus pain, epistaxis, or rhinorrhea.

Musculoskeletal: Positive for slight back pain that relieves on resting. Denies joint pain or muscle cramps.

Breast: Denies ever seeing lumps.

Neurological: Positive for a headache. Denies scotoma, syncope, seizures, or paresthesia.

Heme/Lymph/Endo: HIV negative. No hx of blood transfusion. Denies thyromegally, dysuria, dysphagia, or polyuria.

Psychiatric: Denies depression or any suicidal attempts.

OBJECTIVE

BP: 115/75mmHg

Temp: 98.3 F

Pulse: 82 bpm

Fetal Heart Rate: 140bpm

Resp: 22 bpm

Weight: 127 lbs

Height: 5’ 0.”

BMI: 24.8

General Appearance: Alert and cooperative but looks tired.

Skin: Dry, cold, and moisturized.

HEENT: Atraumatic. No injuries to the scalp. Normocephalic presentation. Ears: External auditory meatus patent and clean. Eyes: Round pupils that change size in response to light. No discharge. Pallor noted on the lids. Neck: No thyromegaly. Full ROM. Nose, Mouth, and Throat: Pink, no exudates. Normal gums. No epistaxis.

Cardiovascular: Palpitations present. No edema of the limbs. Fast heart rate.

Respiratory: Fast breathing. No crackles. Clear lungs.

Gastrointestinal: No bruits. Weak BS. No tenderness or organomegaly.

Breast: Pendulous. No masses or dimpling.

Genitourinary: Normal vulva. Shaven pubic hair. The uterus is behind the bladder. No masses on the labia.

Musculoskeletal: No abnormalities with the fingers. Weak peripheral pulses. Limited ROM of lower limbs. Full ROM of upper extremities.

Neurological: Upright gait. Intact cranial nerves.

Psychiatric: Answers all questions and confirms responses of her husband. Eye contact maintained.

Lab Tests: Full hemogram results reveal that the hemoglobin level is 8gm/dL.

Special Tests: None.

 Diagnosis

 Differential Diagnoses

· 1- Pernicious Anemia: (D51.0) This disease develops when the body cannot absorb vitamin B12, and it leads to fatigue and pallor (Yousaf, Spinowitz, Charytan, & Galler, 2017). PC could be having this diagnosis due to fatigue in the subjective data and pallor in the objective data.

· 2- Hemolytic Anemia: (D59.9). The subjective data shows rapid progression and persistence of the symptoms for the last five days. The objective data reveals parlor. These two symptoms are evidence of hemolytic anemia (Schuiling & Likis, 2016). 

· 3- Aplastic Anemia (D61.9): PC is fatigued and pale, which are the symptoms of aplastic anemia (Bacigalupo, 2017).

Final diagnosis

Iron Deficiency Anemia. (D50.9) The subjective history of PC shows that she lost her appetite ten days ago. Her symptoms of fatigue started five days ago. Both symptoms have persisted up to now. Additionally, she does not have a prescribed diet in spite of being pregnant. Achebeand Gafter-Gvili (2017) argue that inadequate intake of iron can lead to iron deficiency anemia in pregnancy, which could be the case for PC. The physical exam confirms that she is pale, and the HB level is 8gm/dL, which indicates anemia. The loss of appetite in pregnancy and lack of adherence to any given diet form a reliable basis for the diagnosis of iron deficiency anemia.

Plan

Further testing: To be done if further decline of hemoglobin will be evident during follow-up.

Pharmacologic management: None.

Non-pharmacologic management: Folic acid tablets. PC has been given 30 folic tablets, and she will take 600mcg daily until follow-up.

Education: Education has focused on stressing the importance of consuming a balanced diet and consulting with the healthcare providers in case of any challenges regarding planning the meals. PC has been taught to include more of foods that are rich in iron. She has been given examples that include eggs, beans, nuts, green vegetables, fish, and poultry among others. She has also been told to continue taking daily folic tablets and report if she vomits again.

Follow-up: PC should come back after two weeks to check the fundal height, fetal heart rate, HB level, and her general well-being.

Self-Assessment and Clinical Guidelines: This plan can improve the condition of PC since all factors have been considered. For example, PC cooperated and provided explanations of her experiences, which helped to identify symptoms such as fatigue and shortness of breath. Notably, she stopped taking iron supplements. Achebe and Gafter-Gvili (2017) argue that iron supplements are useful since they can prevent anemia in pregnancy. Thus, the diagnosis of iron deficiency anemia was appropriate. Identification of pallor and low hemoglobin level in the objective data helped in confirming the diagnosis. Utilization of iron supplements in the plan can guarantee PC’s recovery. Additionally, Beck, Conlon, Kruger, and Coad (2014) indicate that foods that are high in vitamin C can facilitate absorption of iron. For that reason, PC will be advised during follow-up to consider citrus fruits and strawberry to further enhance the management of anemia.