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.
Week 8 Case 2: Acute Lymphoblastic Leukemia (ALL)
CC: Mrs. Derrick is a 78-year-old female who comes to the office with complaints of increasing symptoms of lethargy; fever, night sweats, a 15 lb. weight loss over 6 months; bleeding gums when she brushes her teeth; purplish patches in the skin; and shortness of breath.
HPI:
She states that she has had sensation of deep pain in her bones and joints.
She notes that her employment history includes working at a dry-cleaning shop for 15 years, with an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias)
PE shows enlarged lymph nodes and swelling or discomfort in the abdomen.
You diagnose this patient with acute lymphoblastic leukemia (ALL).
Address the following in your SOAP note:
What additional history about her past work environment would you explore?
What additional objective data will you be assessing for?
What tests will you order? Describe at least four lab tests.
What are the differential diagnoses that you are considering? Describe two.
List at least two diagnostic tests you will order to confirm the diagnosis of ALL.
Will you be looking for a consultation? Please explain.
As the primary care provider for this patient with ALL:
Describe the education and follow-up you will provide to this patient during and after treatment by the hematologist-oncologist.
Describe at least three (3) roles as the PCP for the ongoing care of the ALL patient.