Nursing Note (Soap note on ANEMIA)

Name:

Date

1). Identifying data

Name: M.A.

Age: 42

Ethnicity: Caucasian

Sex: Female

Chief complaint

“For the past two months I have felt often tired. I also feel like going to the bathroom every five

minutes and I am always really thirsty”

2. Subjective Data

a). History of present illness

M.A. presents with complaints of polydipsia, polyuria, and fatigue for the past two months. She

is able to perform duties but she has a hard time keeping up with play time. Her fatigue has

affected her activity. Fatigue is reduced by rest and increased by exertion.

b) Current health status

M.A. has no known allergies. She intends to get a flu vaccine today. The patient does no drugs or

drinks and does not smoke. She is heterosexual but has not been sexually active for the past six

months. She is currently receiving treatment for hypertension but she says that it has been three

years since her last pap smear and physical examination. She reports that she tries to eat healthy

but due to her busy schedule, her diets mostly consist of fast foods and take outs. She states that

she enjoys play time with her children but the fatigue does not allow time for that.

c) Past medical history

Beside her hypertension, patient states that she is generally in good health. She has had two

hospitalizations for vaginal deliveries. She hasn’t had any surgeries, fractures, fractures, or

childhood illnesses.

d) Social history

M.A. is a single mother of two boys who resides in Riverdale County. She works as a sales rep.

at a clothing store. Patient says that she receives financial help from her sister who lives in the

county. Her children’s father helps by paying child support. She considers her Catholic faith to

be the most important factor to who she is and feels that her spirituality will help in her medical

care.

Patient explanatory mode

“I think I may have diabetes like my grandma and mum.”

d) Family history

 Father- alive with HTN history receiving medication

  Mother-Alive with HTN and DM. Receiving medication

 Sister-Alive with no medical condition

 Children-Alive with no medical complication

e) Systems review

General: Healthy overall

Head/Eyes: no change in vision, eye pain, or headache

Cardiovascular: No chest pain or palpitations

Respiratory: No cough or shortness of breath

Gastrointestinal: No nausea, diarrhea, vomiting, or abdominal pain

Female: LMP was 9/2/19, G3T2D0F2. Placed under IUD 3 years ago for birth control

Musculoskeletal: No back pain, muscle weakness, numbness, or joint pains

Neurological: No change in sight, taste, hearing, or smell

Psychiatric: No history of anxiety or depression

Hematologic: Denies easy bruising or bleeding. Denies anemia

3. Objective Data

a) BP: 124/96 T: 96.7 F P: 81 R: 18 O2 Sat: 100% on RA Ht: 5’5” Wt: 192 Ibs

General: Alert, no acute distress, well-groomed, obese

HEENT: PERRLA, MMM, neck supple, clear oropharynx-no lesion; no enlarged lymph nodes

Cardiac: RRR, normal S1/S2

Pulmonary: symmetrical chest expansion

Skin: no rash, pink and moist

Diagnostic: HgbAlc-9.2, fasting glucose-140

4. Assessment

Medical diagnosis

Type 2 Diabetes

Abnormal glucose levels may be a sign of diabetes. For some test you need to fast before

drawing blood while others are done after meals or any time with no warning. Two or more

plasma glucoses >126mg/dL with symptoms can indicate diabetes (American Diabetic

Association, 2015). An HgbA1C of >6.5 indicates a specific Diabetes diagnosis (McCulloch,

2016). Type 2 diabetes often shows signs of fatigue, polydipsia, and polyuria (Dains, Baumann,

and Scheibel, 2015). Risk factors include family history, obesity, and gestational diabetes. The

patient has all risk factors.

c) Differential diagnosis

Anemia

A CBC to provide information about the cause and degree of anemia; Hemoglobin and

Hematocrit levels reflect the degree of anemia. Total Iron-Binding capacity (TIBC) should be

increase in iron deficiency anemia since although the capacity to bind with iron is high,

hemoglobin is low in both MCV and MCHC.

Hyperthyroidism

Symptoms vary depending on the cause and organ systems affected. Most patients will

experience a combination of anxiety, fatigue, diarrhea, palpitations, heat intolerance, insomnia,

and weight loss. They also have eye complaints such as double vision, blurred vision, and

photophobia. Cardiovascular symptoms include resting heart rate, irregular pulse, systolic

murmurs, and widening of the pulse pressure (Dunphy, Porter, Thomas, and Winland, 2015).

5. Plan

Therapeutics: 2000 calorie diet recommended, 30 minutes exercise per day, and continuous

finger stick glucose monitoring

Pharmacotherapeutics: Metroformin 500mg BID, 120 pills with no refill. Administer

metroformin at diagnosis if not contraindicated to reduce glucose production in the liver,

decrease glucose absorption in the intestine, and improve insulin sensitivity (Williams, 2017).

Diagnostic tests: CMP, UA, thyroid with TSH, lipid panel, microalbuminuria, and serum

creatinine done today. EKG to also be performed immediately. CMP determines the functioning

of the liver and kidney. UA depicts proteinuria and glucosuria. Lab test to determine the patient’s

general medical condition to be performed.

Education

Information on diabetes such as diet, glucose monitoring, exercise, eye care, foot care, and

medication should be given. Provide handouts, resources, and websites for diabetes care.

Follow up: Return to clinic in 8 weeks for repeat HgA1c.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2015). Advanced Health Assessment & Clinical
Diagnosis in Primary Care-E-Book. Elsevier Health Sciences.

Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: Art and
science of advanced practice nursing. FA Davis.

McCulloch, D. K., & Robertson, R. P. (2016). Pathogenesis of type 2 diabetes mellitus. UpTo-
Date.[consultado 12 Fev 2013]. Disponível em: http://www. uptodate.
com/contents/pathogenesis-of-type-2-diabetes-mellitus.

Williams, M. S. (2017). Utilizing Evidence Based Practice to Reduce Hemoglobin A1c Levels in
Primary Care by Increasing Frequency of Office Visits.