Soap Note Example For Anemia

1. IRON DEFICIENCY ANEMIA

PATIENT INITIALS:  T.Q       AGE: 55            SEX: MALE    RACE: WHITE

CC:  Patient came in with iron deficiency anemia and had blood in his stool.

HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old gentleman. He developed deficiency anemia and he had blood in his stool. Anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have haemoglobin of 9 and MCV 65.
PAST MEDICAL HISTORY: Chronic diarrhoea, Chronic obstructive pulmonary disease.
MEDICATIONS: Iron supplement.
ALLERGIES: None.
FAMILY HISTORY: Coronary artery disease, hypertension.  Non history of colon cancer or any type of other cancer.
SOCIAL HISTORY: Patient smokes 1-1/2 packs for more than 40 years. 6 beers per day and no drug history.
REVIEW OF SYSTEMS: No night sweats. Good appetite. Stable weight. No chills, no fevers. No visual problems. No hearing problems. Chronic diarrhoea for more than 3 years. His stool is daily, 1-2 times per day and very loose with dark and bright blood in the stool on and off for more than 5 months. Respiratory review of systems was significant for COPD. Patient not on oxygen and his COPD is mild. Denies any neurological problems, psychiatric problems, endocrine problems, haematological problems, lymphatic problems, immunological problems, allergy problems.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 221 pounds. Height 6 feet 1 inch. Blood pressure 124/62, heart rate 87, and temperature 98.4, saturation 98%. Pain is 0/10.
GENERAL: Good attention to grooming.
HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions. Good dentition.
NECK: Supple.
LUNGS: Clear to auscultation No wheezing and crackles. 

CARDIOVASCULAR: Regular rate and rhythm...
ABDOMEN: No masses, no tenderness. No distention. 

RECTAL: Good sphincter tone. No palpable nodules. No masses. No blood. Dark stool, the patient is taking iron.
BACK: No costovertebral tenderness bilaterally.
LYMPHATICS: None.
MUSCULOSKELETAL: Good, stable gait. No clubbing, no cyanosis, no pitting edema. Full range of motion. No joint deformities.
SKIN: Clear of rashes and lesions.
NEUROLOGICAL: Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both knees and both biceps. No local weakness.
PSYCHIATRIC: Good judgment and insight.
ASSESSMENT & PLAN: Patient needs evaluation for source of bleeding with a colonoscopy. The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality. PSA was in the normal range. The patient had x-ray which showed pulmonary hyperinflation and emphysema. The patient will be followed up with result of colonoscopy.