NR 603 Week 2 Part 3 Summary in SOAP Format
Title: Week 2 Patient Summary in SOAP Format
Subjective:
- Chief Complaint: The patient returns for a follow-up visit four weeks after starting iron supplementation. She reports moderate improvement in fatigue and a reduction in headaches. However, she continues to experience mild fatigue by the end of the day and occasional tachycardia.
- Adherence to Treatment: The patient has been compliant with the prescribed iron supplementation regimen but reports occasional gastrointestinal discomfort, managed by taking the supplement with food.
- New Symptoms: The patient denies any new symptoms and has not experienced significant changes in weight or appetite.
Objective:
- Vital Signs: Blood pressure: 125/80 mmHg, Heart rate: 72 beats per minute, Respiratory rate: 16 breaths per minute, Temperature: 98.4°F.
- General: The patient appears more energetic and less pale than at the initial visit.
- Cardiovascular: Normal heart sounds, regular rhythm, mild tachycardia persists.
- Abdominal: Soft, non-tender, no hepatosplenomegaly, bowel sounds present in all quadrants.
Assessment:
- Improvement in Iron Deficiency Anemia: The patient shows signs of improvement in her anemia with a reduction in fatigue and pallor. However, mild tachycardia persists, which may require further evaluation if it does not resolve with continued treatment.
- Gastrointestinal Side Effects: The patient’s gastrointestinal discomfort is likely related to iron supplementation. The current management strategy of taking the supplement with food appears effective, but alternative formulations may be considered if symptoms worsen.
Plan:
- Continue Iron Supplementation: The patient should continue taking ferrous sulfate 325 mg once daily. To further reduce gastrointestinal side effects, recommend taking the supplement with meals. Consider switching to a lower dose or slow-release formulation if necessary.
- Follow-Up Testing: Schedule a repeat CBC to assess hemoglobin and hematocrit levels. Monitor for any signs of iron overload or other abnormalities.
- Monitor Tachycardia: If tachycardia persists, consider a cardiology referral to rule out any underlying cardiac issues. Continue monitoring blood pressure and heart rate at each visit.
- Patient Education: Emphasize the importance of continuing iron supplementation and dietary modifications. Provide information on managing side effects and the potential risks of non-compliance.
- Next Follow-Up: Schedule a follow-up appointment in four weeks to reassess the patient’s progress and adjust the treatment plan as needed.
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