C1220927

 A

Here is a structured SOAP note for the 15-year-old girl based on all provided data:

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📝 SOAP Note – 15-year-old Female, 

🧠 S – Subjective

• Presenting Complaint: Vomiting, lethargy, intermittent occipital headache worse on sitting up

• History:

  • No fever

  • No photophobia, rash, or neck stiffness

  • Coryzal symptoms intermittently

  • No known chronic medical conditions

  • No recent travel

  • No menstrual history provided yet (TSS/anaemia workup relevant)

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👀 O – Objective

Vitals (initial):

• Hypotensive, tachycardic → received 2x fluid boluses + ongoing IV fluids

• Improving clinically with lactate fall (8.9 → 3.2)

Key Bloods:

Test	Result	Interpretation
Hb	↓ 85 → 70 g/L	Severe microcytic anaemia
Plts	↓ 52 → 48 ×10⁹/L	Worsening thrombocytopenia
Ferritin	↓ 8 ng/mL	Severe iron deficiency
Iron	↓ 2.9 µmol/L	Confirms iron-deficiency
Transferrin Sat	↓ 4%	Consistent with iron deficiency
WCC	19.1 → 12.8	Neutrophilia (reactive?)
MCV / MCH	58.6 fl / 17 pg	Microcytic hypochromic picture
CRP	<1 → 1.9 mg/L	Not significantly raised
Bilirubin	Mild ↑ (25 → 30)	Possible haemolysis or hepatic dysfunction
LDH	Normal	No active haemolysis
BE	-11	Suggests metabolic acidosis
Lactate	↓ from 8.9 → 3.2	Improving perfusion post fluids
CT Head	Normal	No mass, haemorrhage or raised ICP seen

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📋 A – Assessment

15-year-old girl with:

• Severe microcytic anaemia due to iron deficiency

• Thrombocytopenia + initial shock and metabolic acidosis

• Headache but normal CT head

• No fever or overt infection signs; CRP low, neutrophilia present

• Improved with fluids; lactate downtrending

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🧾 P – Plan

🩺 Investigations

• Peripheral blood film – assess morphology, blasts, or schistocytes

• Reticulocyte count – evaluate marrow response

• Clotting profile (PT, aPTT, fibrinogen) – screen for DIC

• Cortisol, ACTH – screen for adrenal insufficiency

• Viral PCRs – EBV, CMV, Parvovirus B19

• ANA, dsDNA, complements – screen for SLE or autoimmune

• Stool for occult blood or consider abdo US – assess for chronic blood loss

• Monitor repeat lactate, U&Es, LFTs, FBC

💉 Management

• Continue IV fluids for perfusion support

• Start iron supplementation (PO or IV depending on tolerance and Hb trend)

• Transfuse red cells if symptomatic or Hb drops further (<70 g/L)

• Consider platelet support if further drop or required for LP

• Start empiric antibiotics if any signs of sepsis develop or source found

🧠 Referral / MDT

• Refer to Paediatrics + Haematology

• Consider PICU if haemodynamic instability persists

• Liaise with Infectious Diseases if evolving systemic features

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Let me know if you'd like this reformatted for handover sheet, referral letter, or consultant review.