Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
Symptoms:
Fatigue (severity and duration)
Weakness
Shortness of breath on exertion
Palpitations
Dizziness
Pale skin
Headache
Restless legs syndrome (if present)
Dietary Habits:
Any dietary restrictions or limitations (vegetarian, vegan)
Intake of red meat, iron-fortified foods, and potential iron-blocking substances (coffee, tea, calcium supplements)
Menstrual History (if female):
Heavy or prolonged menstrual bleeding
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Pallor (conjunctival, mucous membranes)
Cardiovascular: Tachycardia (if present)
Laboratory:
Complete blood count (CBC) with differential:
Hemoglobin and hematocrit levels
Mean corpuscular volume (MCV) – expected to be low in iron deficiency
Mean corpuscular hemoglobin (MCH) – expected to be low in iron deficiency
Mean corpuscular hemoglobin concentration (MCHC) – may be low or normal in iron deficiency
Red blood cell (RBC) indices
Iron studies:
Serum iron
Total iron binding capacity (TIBC)
Ferritin – low ferritin is a strong indicator of iron deficiency
Percentage of transferrin saturation (% saturation) – expected to be low in iron deficiency
Other labs (if indicated):
Reticulocyte count (may be low initially, then increase with iron therapy)
Vitamin B12 and folate levels (to rule out other causes of anemia)
Stool guaiac test or fecal occult blood test (to rule out occult blood loss)
Assessment:
Iron deficiency anemia (based on CBC findings and iron studies)
Severity of anemia (mild, moderate, severe) based on hemoglobin level
Potential cause of iron deficiency (dietary insufficiency, blood loss)
Plan:
Diet: Encourage a diet rich in iron-containing foods (red meat, poultry, fish, beans, lentils, leafy green vegetables) and instruct on spacing iron-fortified foods and iron supplements away from iron-blocking substances (coffee, tea, calcium supplements).
Iron supplementation: Initiate oral iron therapy with appropriate dosing and instructions for administration (on an empty stomach with a glass of water).
Identify and address underlying cause:
If dietary insufficiency is suspected, provide dietary counseling.
If blood loss is suspected, investigate the source (e.g., menometrorrhagia, peptic ulcer disease, hemorrhoids) and address with appropriate treatment.
Repeat laboratory testing:
Monitor CBC with iron studies in [interval] weeks to assess response to treatment. Hemoglobin is expected to rise slowly, with reticulocyte count increasing first.
Follow-up:
Schedule next appointment in [interval] weeks to monitor response to treatment and adjust therapy as needed.