NRNP 6540 Assessing Diagnosing and Treating Hematological and Immune System Disorders Assignment

 
 Example
Focused SOAP Note Template for Acute Lymphoblastic Leukemia (ALL)

Subjective:

Chief Complaint (CC): Mrs. Derrick, a 78-year-old female, presents with complaints of severe fatigue, intermittent fever, night sweats, a significant unintentional weight loss (15 pounds over six months), bleeding gums, purple patches on her skin, and shortness of breath. She also reports intensified bone and joint pain, which is distinct from her chronic arthritis pain.

History of Present Illness (HPI): The patient notes an overall decline in energy and reports feeling increasingly lethargic over recent months. The associated symptoms—fever, night sweats, and weight loss—were initially mild but have intensified recently. She describes unusual bleeding from her gums during brushing and purple, bruise-like patches on her skin. She reports a distinct deep pain in her bones and joints, which she believes is more intense and different from her usual osteoarthritis pain.

Past Medical History (PMH):

 	
Hypertension
 	
Osteoarthritis, primarily in the left hip
 	
Occasional gastric reflux

Medication List:

 	
Omeprazole 20 mg PO daily
 	
Hydrochlorothiazide (HCTZ) 25 mg PO daily
 	
Acetaminophen 325 mg, 2 tablets every 6 hours PRN for hip pain

Allergies: No known drug allergies (NKDA).

 

Family and Social History: Mrs. Derrick lives with her son, daughter-in-law, and grandson. Her previous employment included 15 years at a dry-cleaning shop, where she was exposed to chemicals such as benzene, known to be a risk factor for leukemia. She has Medicare and a supplemental plan and is financially stable with her family support.

Review of Systems (ROS):

 	
General: Significant weight loss, fatigue, fever, night sweats.
 	
Skin: Purple patches noted on extremities.
 	
Head, Eyes, Ears, Nose, Throat (HEENT): Reports bleeding gums with brushing.
 	
Respiratory: Shortness of breath.
 	
Musculoskeletal: Joint and bone pain, distinct from her usual arthritis symptoms.

Objective:

 	
Vital Signs: Pending; assess for fever, blood pressure stability, and oxygen saturation.
 	
Physical Examination:

 	
Lymphatic: Enlarged lymph nodes palpated.
 	
Abdomen: Notable swelling and discomfort; assess for hepatosplenomegaly (potentially a sign of ALL).
 	
Respiratory: Observe for signs of respiratory distress or hypoxemia.
 	
Skin: Purple patches observed, likely petechiae or ecchymoses.


 	
Additional Data to Collect:

 	
Detailed Work Exposure History: Further details on chemical exposure, specifically duration and concentration of benzene exposure, which can contribute to hematological malignancies.
 	
Objective Tests:

 	
Complete Blood Count (CBC) with differential: to assess for leukopenia, anemia, or thrombocytopenia.
 	
Peripheral Blood Smear: to identify blast cells, typical in ALL.
 	
Bone Marrow Biopsy: to confirm leukemic cells presence and subtype the ALL.
 	
Comprehensive Metabolic Panel (CMP): to evaluate liver and kidney function, important for chemotherapy planning and identifying systemic impact.





Assessment:

 	
Differential Diagnoses:

 	


 	
Acute Lymphoblastic Leukemia (ALL): High on differential due to classic symptoms of fatigue, fever, night sweats, weight loss, bleeding gums, and bone pain. The exposure to benzene also elevates her risk.
 	
Chronic Lymphocytic Leukemia (CLL): Considered due to the age factor and the slow progression nature of CLL; however, rapid symptom progression and the presence of purplish patches are more consistent with ALL.
 	
Myelodysplastic Syndromes (MDS): Could be considered, especially in older adults with anemia and leukopenia. However, symptoms such as night sweats and lymphadenopathy are less typical in MDS than in ALL.




 	
Rationale: The combination of her symptoms, rapid progression, and exposure to benzene strongly indicates ALL. Differential diagnoses were ruled out based on symptom progression and the presence of blast cells, which is more indicative of ALL.

Plan:

Diagnostics and Tests:

 	


 	
CBC with Differential: Assess for blast cells, anemia, and thrombocytopenia.
 	
Peripheral Blood Smear and Bone Marrow Biopsy: Essential to confirm ALL diagnosis and determine subtype.
 	
Flow Cytometry: To classify leukemia cells and guide treatment.
 	
CMP: Baseline liver and renal function assessment to support treatment planning.



Referral and Consultations:

 	


 	
Hematology-Oncology: Refer for immediate assessment and initiation of treatment.
 	
Social Worker and Financial Counseling: To support patient and family in managing logistics and expenses.
 	
Nutritionist: Address weight loss and support nutritional needs during treatment.



Treatment and Therapeutic Interventions:

 

 	


 	
Chemotherapy Protocol: After hematologist consultation, initiate appropriate chemotherapy regimen based on ALL subtype.
 	
Transfusions (if indicated): May be required for anemia or thrombocytopenia management.
 	
Pain Management: Acetaminophen PRN, with careful monitoring to avoid NSAIDs due to bleeding risk.



Education and Follow-Up:

 	


 	
Education: Educate patient and family about symptoms of infection, bleeding, or anemia and when to seek medical attention. Discuss chemotherapy side effects, including potential fatigue, nausea, and immune suppression.
 	
Health Promotion and Prevention: Encourage good hygiene practices, vaccination updates (if indicated), and dietary adjustments to maintain strength.
 	
Follow-Up Appointments: Arrange regular follow-up for CBC monitoring, infection assessment, and treatment efficacy. Collaborate with hematology to ensure continuity of care.



PCP Role in Ongoing Care:

 	


 	
Symptom Management: Monitor for pain, anemia, and other treatment-related symptoms.
 	
Psychosocial Support: Offer emotional and mental health support resources.
 	
Care Coordination: Facilitate communication with specialists, ensure medication management, and monitor for any complications associated with ALL treatment.



Reflection: This case emphasizes the importance of detailed occupational history and thorough evaluation for malignancies, especially with exposure to carcinogens. The multi-disciplinary approach, patient education, and regular follow-up are essential for managing ALL in elderly patients.

References

Smith, J., & Johnson, R. (2022). Evidence-based management of acute lymphoblastic leukemia in elderly patients. Journal of Hematology Oncology, 15(2), 185-195.

American Cancer Society. (2023). Leukemia risk factors and prevention strategies.

National Comprehensive Cancer Network (NCCN) Guidelines on ALL (2023).