SOAP Note- Assessing Hematological and Immune system disorders essay

Case Scenario

Mrs. L. is a 68 years old female who presents with easy fatigability, general body weakness, and breathlessness. She takes Lipitor because of elevated cholesterol levels. She has undergone an appendectomy and hysterectomy. The pulse rate is elevated at 98beats/min, she is pale, and has tachyarrhythmia with regular soft mid-systolic murmur. Her colonoscopy test shows she has a neoplasm in the colon. SOAP Note- Assessing Hematological and Immune system disorders essay

Subjective Data

Patient Particulars

Initials: Mrs. L.

Age: 68years

Gender: Female

Race: American

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Chief complaint: generalized body weakness and breathlessness

History of the presenting complaint:

Mrs. L. is a 68 years old American female who presented with generalized body weakness and breathlessness. The generalized body weakness was of gradual onset, associated with headache, lightheadedness, fast and unusual heartbeat, and breathlessness. However the patient denies history of paroxysmal nocturnal dyspnea and orthopnea.

Current medication: Lipitor

Allergies: none

Immunization: up to date

PMH: Elevated cholesterol levels, uterine myoma and appendicitis

Surgery: Appendectomy and hysterectomy

Family History: No reported history of chronic illnesses in her family.

Social History: She is a widower, her husband died nine months ago. She has two daughters who live nearby. She denies smoking tobacco and drinking alcohol.

REVIEW OF SYSTEMS:

General: the patient presents with easy fatigability, general body weakness, and weight loss.

Cardiovascular: patient reports of chest pain that is on and off, palpitations, and dyspnea. SOAP Note- Assessing Hematological and Immune system disorders essay

CNS: the patient denies reports of lightheadedness, and syncope. She denies history of tingling in the lower and upper extremities

Respiratory: The patient denies sub-sternal chest pain, difficulty in breathing, cough, wheezing shortness of breath, exposure to TB, or second-hand smoke. Up to date with flu immunization.

HEENT: The patient reports of headaches. She denies history of head trauma, changes in vision, epistaxis, ringing in the ears, eye, hearing loss, and ear discharge.

Musculoskeletal: The patient has no joint pains, no pedal edema, and no stiffness, muscle pain, and back pain.

Emotional: The patient reports of low mood since the demise of her spouse. She denies history of anxiety, or depression.

Neurological: The patient maintains a normal gait, no tremors or seizures, has no tingling and numbness.

Skin: No bleeding, rashes or other lesions, slightly warm to touch.

Endocrine: no night seats, no bruising, heat/cold intolerance, no blood disorders or swollen lymph nodes.

Objective Data

General examination: The patient is alert, well groomed, and well-nourished. She has conjunctiva pallor, no cyanosis, no edema, no lymphadenopathy, no dehydration, and no finger clubbing.

Vitals: blood pressure 106/70mmHg, heart rate 98beats per minute, temperature 36.6, body mass index of 22

Head: The skull is normal-cephalic, and without masses.

Eyes: The eyelids are normal without lesions. The sclera is white and the conjunctiva pale. Pupils are equally round and reactive to light and accommodation.

ENT: External inspection of ears and nose is normal without scars, or masses. The mucosa is pink and moist.

Neck: The neck is supple and the trachea is midline. The thyroid is not enlarged and there are no palpable nodules.

Breast: Inspection of the breasts reveals symmetrical and smooth breasts bilaterally without skin color changes, lesions, dimpling or skin retraction. The nipples are averted and without discharge or lesions. The breast tissue is non-tender and smooth.

Respiratory: The chest wall is symmetrical and is moving with respiration, the patient is not cyanotic and does not use the accessory muscles of respiration. Upon palpation of the chest wall there is no tenderness or masses. The lungs are clear to auscultation. There are no crackles, wheezes, rhonchi, stridor or pleural rubs.

Cardiovascular: The peripheral pulses are rapid and strong. There are no heaves, lifts, or thrills. The heart rate is tachyarrhythmia, S1 and S2 are present. There are soft mid-systolic murmurs. There are no gallops and there are no rubs. There is no pitting edema of the lower extremities, and there are no bruits.

Gastrointestinal: The abdomen is soft and non-tender; there is no guarding or rigidity. Bowel sounds are normal. There are no palpable masses. There is no hepatosplenomegaly. There is no costovertebral angle (CVA) tenderness. SOAP Note- Assessing Hematological and Immune system disorders essay

Genitourinary (F): The external genitalia are normal without erythema, lesions, or masses. Vaginal mucosa is pale and without discharge.

Lymphatic: There is no cervical, axillary, or inguinal lymphadenopathy.

Extremities: Inspection and palpation of digits and reveals no clubbing, cyanosis, or Osler's nodes.

Dermatologic: The skin is normal in texture, color, temperature, moisture, mobility and turgor. There are no abnormal lesions. The hair is in a normal distribution with a normal texture.

Psychiatric: The patient is oriented to time, place and person. The patient's mood is neutral and the affect is flat. The speech rate and quantity is normal and the volume is well modulated. The patient is articulate, coherent; and spontaneous. The flow of words is consistent with normal fluent speech. The patient's thought processes are logical, relevant, organized and coherent. The patient's associations are intact. There are no obsessive, compulsive, phobic, delusional thoughts. There are no illusions or hallucinations. The patient’s judgment concerning everyday activities and social situations is good and insight into their condition is appropriate. SOAP Note- Assessing Hematological and Immune system disorders essay

Assessment

Differential diagnosis

Anemia secondary to colorectal carcinoma

Hypercholesterolemia

Anemia is described as decreased red blood cells mass transporting oxygen and carbon dioxide. It impairs the body’s ability for gaseous exchange. Causes of decreased red blood cell mass are blood loss, increased destruction of RBCs, and decreased production of the RBCs. Anemia may also be caused by acute blood loss, malignant diseases, and sepsis (Manchanda, N. 2019). Decreased oxygen supply in the body presents with generalized body weakness, headache, shortness of breath, and palpitations. In this case scenario, the patient has similar symptoms as of those of anemia. The most probable cause of the anemia is colon neoplasia which is also explained by the rapid weight loss. SOAP Note- Assessing Hematological and Immune system disorders essay

Hypercholesterolemia is defined as high plasma cholesterol levels due to elevated low density lipoproteins. Hypercholesterolemia presents with extreme fatigue, shortness of breath, chest pain and cold extremities (Sturm, et al, 2018). It predisposes a patient to coronary heart disease which presents with tachyarrhythmia and murmurs. The patient is known to have hypercholesterolemia and is on treatment.

Plan

Diagnostic investigations

Diagnostic investigations appropriate for this patient are full hemogram to rule out the cause of the anemia (malignancy or acute blood loss). Lipid profile test checks on the levels of low density and high density lipoproteins. . Stool test to determine blood loss through the rectum. Urinalysis checks for infections and blood loss through urine.

Treatment plan

Pharmacological

Lipitor and folate supplements

Non-pharmacological

The patient should have adequate rest, take adequate amount of water, and take food rich in iron to facilitate in blood formation. SOAP Note- Assessing Hematological and Immune system disorders essay

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Assignment: Assessing, Diagnosing, and Treating Hematological and Immune System Disorders Many factors affect patients’ hematological and immune status. Additionally, manifestations of these disorders may appear in different organ systems. As an advanced practice nurse, you must be able to diagnose and treat patients with hematological and immune status disorders by prescribing necessary treatments, assessments, and follow-up care. Photo Credit: Getty Images/Westend61 To prepare: Review the case study provided by your Instructor. Reflect on the patient’s symptoms and aspects of disorders that may be present. Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case. Access the Focused SOAP Note Template in this week’s Resources. The Assignment: Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following: Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems. Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. SOAP Note- Assessing Hematological and Immune system disorders essay  Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned. Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting. SOAP Note- Assessing Hematological and Immune system disorders essay