SOAP Note: 28-Year-Old Female with Iron Deficiency
Subjective
- 28-year-old female presenting for follow-up on laboratory results 1
- Document presence or absence of: fatigue, exercise intolerance, heavy menstrual bleeding, dietary restrictions (vegetarian/vegan), history of gastrointestinal symptoms, or recent blood donation 2, 3
- Assess for symptoms of iron deficiency even without anemia: reduced exercise tolerance, lethargy, cognitive difficulties 2
Objective
- CBC: Within normal limits (hemoglobin ≥12 g/dL for non-pregnant women) 1
- CMP: Within normal limits 1
- Ferritin: 5 ng/mL (critically low, <15 ng/mL has 99% specificity for absolute iron deficiency) 4, 1
- Vital signs: [document if available]
- Physical examination: [assess for pallor, tachycardia, signs of underlying bleeding source]
Assessment
Iron deficiency without anemia (Stage 1 iron deficiency) 4, 2
- Ferritin of 5 ng/mL confirms absolute iron deficiency with depleted body iron stores 4, 1
- Normal hemoglobin indicates iron stores are depleted but erythropoiesis remains adequate at present 4
- This represents the earliest stage of iron deficiency, occurring before development of microcytic anemia 2
- Iron deficiency at this stage still causes significant symptoms including fatigue and reduced physical performance, warranting treatment 2, 3
Plan
1. Investigate Underlying Cause
For premenopausal women with iron deficiency, GI evaluation is conditional rather than mandatory 1
- Perform non-invasive testing for H. pylori and celiac disease serologies 1
- If testing negative and patient is young with heavy menses, empiric iron supplementation alone is reasonable 1
- Reserve bidirectional endoscopy for: positive H. pylori/celiac testing, GI symptoms, persistent iron deficiency despite adequate supplementation, or age >50 years 1
- Assess menstrual blood loss; if heavy, consider gynecologic evaluation and management 3
2. Iron Supplementation Protocol
Initiate oral iron supplementation immediately 4, 2
Dosing regimen:
- Prescribe ferrous bisglycinate or ferrous sulfate 30-60 mg elemental iron daily 1, 2, 5
- Alternate-day dosing (60 mg every other day) may improve absorption and reduce gastrointestinal side effects compared to daily dosing 1, 5
- Take on empty stomach for optimal absorption, or with meals if gastrointestinal symptoms occur 6, 2
- Avoid taking within 2 hours of tetracycline antibiotics, calcium supplements, or antacids 6
Expected side effects (counsel patient):
- Black stools (benign) 6
- Constipation, nausea, or diarrhea (minimize by taking with food or switching to alternate-day dosing) 6, 1
3. Dietary Counseling
- Increase dietary heme iron sources: red meat, poultry, fish 2, 3
- Enhance iron absorption with vitamin C-rich foods 2
- Avoid iron absorption inhibitors (tea, coffee, calcium) around iron-rich meals 2
4. Follow-Up Testing
Repeat CBC and ferritin in 8-10 weeks 1, 2
- Expected response: hemoglobin increase of 1-2 g/dL if anemia develops, ferritin >30 ng/mL 7, 2
- Target ferritin >100 ng/mL to restore iron stores and prevent recurrence 1, 4
- If no improvement: consider malabsorption, non-compliance, ongoing blood loss, or need for IV iron 7, 2
5. Long-Term Management
For patients with recurrent low ferritin (menstruating females, vegetarians, athletes):
- Screen ferritin every 6-12 months 4, 2
- Consider intermittent oral iron supplementation to maintain stores 2
- Do not continue daily iron supplementation once ferritin normalizes, as this is potentially harmful 2, 1
6. Patient Education
- Iron deficiency causes symptoms even without anemia 2, 3
- Treatment duration typically 3-6 months to replete stores 2
- Report worsening fatigue, new GI symptoms, or lack of improvement 1
- Accidental iron overdose is a leading cause of fatal poisoning in children under 6; store medication safely 6
7. Red Flags Requiring Urgent GI Evaluation
- New or worsening GI symptoms (abdominal pain, change in bowel habits, blood in stool) 1
- Failure to respond to adequate oral iron therapy after 8-10 weeks 1, 7
- Age >50 years (higher risk of GI malignancy) 1, 7
Return to clinic in 8-10 weeks for repeat labs and clinical reassessment 2, 1