Hematological and Immune Disorders Homework Help

Focused SOAP Note For Nurse Practitioners

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. 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.

Week 8 Case 1: Anemia in Older Adult

CC: Mrs. L., a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling weak and like “I can’t catch my breath sometimes.”

HPI: She has been healthy except for high cholesterol, managed by Lipitor. Her husband died 9 months ago, and she has attributed her fatigue to dealing with his death but realizes that she is feeling worse and not better as time passes.

No known drug allergies.

Medications: Takes only Lipitor.

Past surgical history: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.

No significant medical history. Has two daughters living nearby.

Blood pressure (BP) 106/70 mm Hg, heart rate (HR) 98 beats/min and regular, respiratory rate 18 breaths/min and afebrile, body mass index (BMI) 22 (10-pound weight loss since death of husband).

Slender, quiet-spoken older woman appearing tired.

PE: Conjunctiva pale, mucous membranes moist. No lymphadenopathy of neck or femoral area.

Heart tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement.

Abdomen soft, bowel sounds × 4.

Diagnostics:

Urine dipstick negative.

The results of a colonoscopy show a neoplasm in the colon.

Address the following in your SOAP note:

1. What additional subjective data are you seeking?
2. What additional objective data will you be assessing for?
3. What medical history would you obtain from the patient?List at least three.
4. What tests will you order? Describe at least four lab tests.
5. What are the differential diagnoses that you are considering? Describe two.
6. What is your plan of care? List at least two diagnostic tests you will order to evaluate the cause of her condition.

Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S (subjective)

CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).

HPI(history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATESfor the HPI might look like the following example:

• Location: Head
• Onset: 3 days ago
• Character: Pounding, pressure around the eyes and temples
• Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
• Timing: After being on the computer all day at work
• Exacerbating/relieving factors: Light bothers eyes;Aleve makes it tolerable but not completely better
• Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versusintolerance.

PMHx:Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

SocandSubstance Hx:Include occupation and major hobbies, family status, tobacco andalcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relativesshould be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx:Prior surgical procedures.

Mental Hx:Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx:Concern or issues about safety (personal, home, community, sexual (current andhistorical).

Reproductive Hx:Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).

ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:

• General:
• Head:
• EENT (eyes, ears, nose, and throat):
• Etc.:

Note: You should list these in bullet format, and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT:

• Eyes:No visual loss, blurred vision, double vision or yellow sclerae.
• Ears, Nose, Throat:No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN:No rash or itching.

CARDIOVASCULAR:No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:No shortness of breath, cough or sputum.

GASTROINTESTINAL:No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.

NEUROLOGICAL:No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:No anemia, bleeding or bruising.

LYMPHATICS:No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:No history of depression or anxiety.

ENDOCRINOLOGIC:No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE:Not pregnant and no recent pregnancy.No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES:No history of asthma, hives, eczema or rhinitis.

O (objective)

Physical exam: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e.,General: Head: EENT: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A (assessment)

Differential diagnoses:List a minimum of threedifferential diagnoses.Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

P (plan)

Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Also included in this section is the reflection.Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).

References

You are required to include at least threeevidence-basedpeer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7thedition formatting.

Sample Hematological and Immune Disorders Questions & Answers

Chronic kidney disease impacts many systems in the body. what is the number one hematologic disorder caused by ckd?

What is the difference between immune disorders and autoimmune disorders?