Question

Scenario G.C. is a 78-year-old widow who relies on her late husband's Social Security income for all of her expenses. Over the past few years, G.C. has eaten less and less meat because of her financial situation and the trouble of preparing a meal "just for me." She struggles financially to buy medicines for the treatment of hypertension and arthritis. She goes to the outpatient clinic complaining that over the past 2 to 3 months she has felt increasingly tired, despite sleeping well at night. Her vital signs (VS) are 136/76, 16, 80. She denies any dyspnea or palpitations. The nurse practitioner orders blood work. G.C.'s chemistry panel findings are all within normal limits and a stool guaiac test result is negative. Her other results are shown in the chart.

Chart View Laboratory Test Results White blood cell (WBC) count 7600/mm3 Hematocrit (Hct) 27.3% Hemoglobin (Hgb) 8.3 mg/dL Platelets 151,000/mm3 Red Blood Cell (RBC) Indices Mean corpuscular volume (MCV) 65 mm3 Mean corpuscular hemoglobin (MCH) 31.6 pg MCH concentration (MCHC) 35.1% Red cell distribution width (RDW) 15.6% Iron (Fe) 30 mcg/dL Total iron-binding capacity (TIBC) 422 mcg/dL Ferritin 8 mg/dL Vitamin B12 414 pg/mL Folate 188 ng/mL

1. Which question would best help you determine the impact of fatigue on her activities of daily living?

1. "Are you upset about feeling more tired?
2. "How far can you walk until you get short of breathe?"
3. "Have you been able to do what you would like to do?"
4. "Do you sleep more now than you used to?

2. What evaluative parameters could you use to determine whether G.C.'s condition is improving?

3. Using SOAP, write a sample documentation entry for this encounter.

Thank you in advance!!!!!

Thank you in advance!!!

Answer 1

1. Fatigue is a weariness caused by exertion. Patient may use the words tired, exhausted or lethargic to describe the word fatigue.

Answer: C : Have you been able to do what you would like to do ,

Fatigue interferes with the Activities of Daily Living, as patient may feel increased tiredness, while doing activities. She may lack the motivation to initiate the activities due to fatigue.  

Other options are wrong:

a) Patient feels upset for being tired every time, but the question may not describe the impact of fatigue on ADLs.

b) Shortness of breath and fatigue is not same.

d) She is having adequate sleep at night. Sleeping at day time may be a symptom of drowsiness. Drowsiness and fatigue are different.  

2. G.C ' s Condition:

Abnormal lab values:

Heamatocrit: 27.3 % - Decreased ( normal value 38- 47 % )

Haemoglobin: 8.3 mg / dL - Decreased ( 12 - 16)

MCV , MCH are normal but,

MCH concentration ( MCHC) : 35.1% - increased (  27- 31 %)

Fe , Iron : 30 mcg/ dL - Decreased ( 35 - 40 mcg / dL)

Total Iron Binding Capacity ( TIBC ): 422 mcg / dL - increased , indicates that circulating iron levels are low.

Vitamin B12 and Folate are normal.

GC 's lab results show that she is having Anaemia as her Haemoglobin level is low . Lab results for Iron and TIBC are abnormal , it indicates that she is having Iron deficiency Anaemia.  

To check whether GC's condition is improving, one must check the evaluative parameters of:

* Heamatocrit

* Haemoglobin

* Iron

* TIBC

* MCHC concentration

( Normal range is given above)

3. SOAP:

It is a method of Medical documentation used by Health care providers.

S- Subjective  

O- Objective

A- Assessment

P- Plan

SOAP Documentation for the Scenario:

S- G.C , a 78 year old widow comes in to Outpatient clinic with the complaints of fatigue, since 2 -3 months . She complaints about the increased tiredness despite of her adequate sleep at night time. She denies dyspnoea and palpitations.  

She is having financial struggle, even to by the medications for her Hypertension and arthritis.

She is not having adequate diet as she don't have money to spend for meat and other nutritious food.  

O- G.C 's vital signs : B.P : 136/ 76 mm of Hg, Pulse - 80 beats per minute , resp- 16 breaths / minute.

Her lab work up on blood studies show the abnormalities in Haemoglobin( 8 mg/ dL) , Heamatocrit ( 27.3%),  MCHC ( 35.1 %), and TIBC ( 422 mcg / dL)

Stool guaiac test is negative and blood chemistry panel shows normal results.  

A- G.C , 78 year old , with Iron deficiency Anaemia, having fatigue from 3 months, not able to complete her Activities of daily living due to increased tiredness

P-

- Instruct her to take Iron rich food like beans , lentils , baked potatoes , dark green leafy vegetables, cashew and fortified breakfast cereals etc.

- Assist her to develop a schedule for Daily activity and rest

- Encourage her to take frequent rest periods in between the activities

- Instruct her to take Iron supplements according to physician's order

- Encourage her to add fiber rich food items to daily diet to prevent constipation, as a result of Iron supplements.