Create a SOAP for the case attached and using the templates also attached, no AI, only 20 % plagiarism, with two or more references in APA styleSOAPanemia.

· Semester: Fall

· Course: MSN5700C Advanced Practice in Primary Care I

· Preceptor: Rural Visit: No

· Underserved Area/Population: Yes

Patient Demographics

· Age: 42 years

· Sex: Female

· Race: Hispanic

· Insurance: PPO

· Referral: No referral

Reason for Visit: Follow-up Type of Decision-Making: Moderate Chief Complaint: “I’m here for follow-up of my anemia and fibroids; they are planning surgery.” Type of H & P: Follow-up visit

History of Present Illness (HPI): A 42-year-old Hispanic female presents for follow-up of chronic anemia related to abnormal uterine bleeding secondary to uterine fibroma. She reports history of heavy, prolonged menstrual periods for over a year, associated with fatigue and weakness. She was previously diagnosed with uterine fibroids and is scheduled for hysterectomy once her hematologic status is optimized. She continues oral iron supplementation. Denies chest pain, palpitations, or shortness of breath at rest.

Past Medical History:

· Chronic iron-deficiency anemia

· Uterine fibroma

Medications:

· Ferrous sulfate 325 mg PO daily

· Multivitamin

Physical Exam (Pertinent):

· General: Alert, oriented, in no acute distress.

· Vitals: Stable.

· Cardiovascular: Regular rate and rhythm, no murmurs.

· Respiratory: Lungs clear bilaterally.

· Abdomen: Soft, non-tender, no masses palpated.

· Extremities: No edema.

Assessment/Plan:

1. Chronic Iron-Deficiency Anemia (D50.9): Continue iron supplementation, reinforce adherence, recheck CBC in 4 weeks.

2. Uterine Leiomyoma (D25.9): Candidate for hysterectomy; optimize preoperative status with hematology clearance.

3. Menorrhagia with Regular Cycle (N92.0): Symptom management until surgical intervention.

Plan: Continue oral iron, encourage iron-rich diet, follow-up labs (CBC, iron studies). Surgery planning coordinated with gynecology. Educated patient about importance of compliance with treatment to improve hemoglobin before procedure.

Social Problems Addressed:

· Growth & Development (reproductive health)

· Income/Economic (impact on work due to fatigue, planning for surgery)

Clinical Notes (Typhon text box): Female patient with chronic anemia secondary to heavy menstrual bleeding caused by uterine fibroids. Currently managed with iron supplementation and scheduled for hysterectomy once hemoglobin is optimized. Patient reports improved energy with therapy, denies chest pain or SOB. Plan includes continued oral iron, dietary counseling, and repeat labs. Coordination with gynecology for surgical clearance.

ICD-10 Diagnosis Codes:

· D50.9 – Iron deficiency anemia, unspecified

· D25.9 – Leiomyoma of uterus, unspecified

· N92.0 – Excessive and frequent menstruation with regular cycle

CPT Codes (Billing/Labs):

· 85027 – CBC, automated

· 83540 – Iron studies

· 36415 – Venipuncture, routine

,

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications: (including OTC and vitamins)

·

PMH:

Immunizations:

Preventive Care: Preventive Screenings: (for results already obtained before this encounter) – Pap smear: ______ – Mammogram: ______ – Colonoscopy: ______ – Lipid panel: ______ – A1C: ______ – STI screen: ______ – Depression screen (PHQ-9): ______

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATE

Chief Complaint (which must be stated between “__”)

Symptom analysis/HPI:

Clinical Tools Used (if applicable), otherwise state N/A – PHQ-9: ___ /27 – GAD-7: ___ /21 – AUDIT-C / DAST:

Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

OBJECTIVE DATA

VITAL SIGNS: LABS / DIAGNOSTICS REVIEWED (if available): – CBC: – Lipid Panel: – A1C: – EKG: – Imaging (if done):

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT

Red Flags / Reasons for Escalation: – [ ] None noted – [ ] Positive suicidal ideation – [ ] Unstable vital signs – [ ] Abnormal exam requiring urgent referral

Clinical Note

(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)

Example: “Pt came into our clinic today c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… On examination I noted erythema in the ear canal…, 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) along with the rationale behind them. (why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)

–

–

–

PLAN

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones – tailored to this specific patient – not in general)

Follow-ups/Referrals

Visit Complexity / CPT Code: _______

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).

The post Create a SOAP for the case attached and using the templates also attached, no AI, only 20 % plagiarism, with two or more references in APA styleSOAPanemia. first appeared on Ehomeworker.