Assessing, Diagnosing, and Treating Hematological and Immune System Disorders Focused SOAP Note

Assessing, Diagnosing, and Treating Hematological and Immune System Disorders

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 assessment 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 is 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 differential 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.

Solution

Focused SOAP Note

Patient Information:

Initials: J. M.                            Age: 71 years old                         Sex: Female

S (subjective)

CC: “J. M. is increasingly fatigued and she has a dry skin”

HPI: Ms. Juggenmier is a 71-year old female who has come to the office complaining of increased fatigue and dry skin. She does report increased fatigue no matter how much sleep she gets.  She does not want to travel as she thinks she does not have the energy. She notices lack of energy and activity tolerance with her golf games. She has been offered a golf cart and for the first time ever she is riding instead of walking. She has no pain and has had no falls. She wishes her physical health were as good.

She thinks she may have gained a few pounds but also attributes that to the new boots she is wearing as they are quite heavy. Her friends are concerned as they have walked with her for golf and this fatigue is different for their friend. She is also concerned that she may need to stop one of her medications because her hair is thinning.

She had labs done with her annual physical two weeks ago. This is her follow up appointment. She was informed they would review results at this visit, however, her primary concern is her fatigue that is interfering with her quality of life. She admits to not taking her vitamin D daily as prescribed. She has added, on her own, a vitamin B 12 1000 mcg daily to add energy.

• Location: General body weakness.
• Onset: Not reported.
• Character: Lack of energy and activity tolerance.
• Associated signs and symptoms: Increased fatigue, dry skin, and lack of energy.
• Timing: When walking and performing physical tasks.
• Exacerbating/relieving factors: Fatigue does not improve even with enough sleep.
• Severity: She has no pain.

Current Medications:

• Women’s One A Day-Multivitamin daily
• Chlorthalidone 25mg daily
• Fish Oil 1 tablet daily
• Amlodipine 5mg p.o. daily
• Losartan 100mg p.o. daily
• Atorvastatin 40mg p.o. at bedtime daily
• Aspirin 81mg p.o. daily
• Ergocalciferol 50,000 units PO once a month

Allergies: Her only stated allergy is Lisinopril.

PMHx: J. M. reports that she has had shingles over a year ago. She has not had the “shingles shot” because now that she has had shingles surely she will not have them again. She has frequent colds and cold sores, new for her. Other diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency.

Soc and Substance Hx: J. M. lives alone in the home where she has lived for twenty-five years. She never married and has no children. She has many long-time friends and is socially active and a volunteer in her community. Her hobbies include painting with water colors and golf. She has never used tobacco. She drinks wine socially on occasion but never more than a glass or two twice weekly. She never drinks alone. In retirement she is financially comfortable and that allows her to travel a few times each year.

Fam Hx: No family history reported.

Surgical Hx: No prior surgical procedures reported.

Mental Hx: J. M. reported in the survey at the time of her annual physical that her mental health is excellent.

Violence Hx: No concern or issues about safety reported.

Reproductive Hx: No reproductive history reported.

ROS

General: J. M. reports that she has gained a few pounds lately.

HEENT:

• Head: Denies head injury. She reports thinning of hair.
• Eyes: Denies blurred vision or visual loss.
• Ears: No hearing loss,
• Nose: No sneezing, no nasal congestion, no runny nose.
• Throat: Denies sore throat.

SKIN: Dry skin.

CARDIOVASCULAR: Denies chest discomfort or chest pain.

RESPIRATORY: Denies cough; denies shortness of breath. Reports increased fatigue.

GASTROINTESTINAL: No nausea, no vomiting, no abdominal pain, no diarrhea.

GENITOURINARY: Date of last menstrual period (LMP) not given. Denies burning sensation during urination.

NEUROLOGICAL: Denies numbness or tingling in the extremities, no headache. Denies changes in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, no back pain, denies joint stiffness, denies falls.

HEMATOLOGIC: Increased fatigue.

LYMPHATICS: Denies history of splenectomy; No enlarged nodes.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Reports cold intolerance. Denies abnormal sweating at night, No enlarged thyroid.

REPRODUCTIVE: No reports of vaginal or penile discharge.

ALLERGIES: J. M. is allergic to Lisinopril.

O (objective)

Physical exam:

Vital signs:

Blood pressure: 128/64, pulse 65, temperature 97.1 F, Respiratory rate 20, height 1.778m (5′ 10″), weight 74.8 kg (164 Ib 14.5 oz), Sp02 95 %.

General: J. M. is alert, oriented, and ambulatory. She easily describes her concerns.

HEENT:

Head: J. M.’s head is normacephalic. Her hair is black. She has hair distributed throughout the skull. His hair is black in color. Evidence of hair thinning observed.

Eyes: Both eyes are sensitive to changes in light intensity. Her conjunctiva is moist.

Ears: The ear canal is without lesions and is clear. Her ears are sensitive to sound.

Nose: J. M.’s nose has hair evenly distributed on the mucosa. The nasal mucosa is pink in color and is moist. No evidence of nasal congestion.

Throat: No lesions in her buccal mucosa which is pink and moist. No evidence of erythema on her throat.

Neck: J. M. has trachea positioned midline. Neck is upright and has no evidence of swelling. No evidence of neck pain.

Breast: No evidence of lumps or discharge on both breasts. Breasts are positioned bilaterally.

Lungs: Both lungs can expand normally during inhalation and exhalation. No wheezing.

Cardiovascular/Heart: No gallop, no heart murmurs, no edema.

Abdomen: Auscultation reveals no evidence of bowel sounds. No abdominal distention, no tenderness.

Musculoskeletal: No issues with gait. No evidence of joint pain on touching. J. M. can stretch her legs and arms comfortably without any difficulties.

Genitourinary: No evidence of itching.

Neurological: Cold intolerance. No evidence of motor or sensory deficits.

Skin: The skin surface appears rough, scaly, and dry.

Hematologic: Increased fatigue.

Diagnostic results:

1. CXR- Last cxr showed no cardiopulmonary findings. WNL
2. TSH/Free T4, T3- as noted below in lab results
3. Basic Metabolic Panel and CBC as shown below
4. Vitamin D Level- as noted below in lab results

 

TEST	RESULT	REFERENCE RANGE
GLUCOSE	85	65-99
SODIUM	134	135-146
POTASSIUM	4.2	3.5-5.3
CHLORIDE	104	98-110
CARBON DIOXIDE	29	19-30
CALCIUM	9.0	8.6- 10.3
BUN	20	7-25
CREATININE	1.01	0.70-1.25
GLOMERULAR FILTRATION RATE (eGFR)	76	>or=60 mL/min/1.73m2

 

TEST	RESULT	REFERENCE RANGE
TSH	23	0.4-4.0
FREE T4	0.05	0.9-2.4 mcg/dl
T3	3.0	2.0-4.4 ng/dl
Vitamin D 1,25 OH	14	36-144

 

TEST	RESULT	REFERENCE RANGE
WBC	7.3	3.4- 10.8
RBC	4.31	135-146
HEMOGLOBIN	14	13-17.2
HEMATOCRIT	42%	36-50
MCV	90	80-100
MCHC	34	32-36
PLATELET	272	150-400

A (Assessment)

Differential diagnoses:

• Hypothyroidism (Primary diagnosis)
• Iron-deficiency anemia
• Chronic fatigue syndrome

Explanation

Hypothyroidism (Primary diagnosis)

Hypothyroidism occurs when the body is unable to produce sufficient levels of thyroid hormone. Changes in levels of thyroid hormone have a number of etiologies including an autoimmune disorder, iodine deficiency, and certain medications including amlodipine, stavudine, and thalidomide, among other drugs (Patil et al., 2021). Other risk factors of hypothyroidism include old age above 60 years, family history of the disease, and a history of neck/head irradiation.

Common signs of hypothyroidism include dry skin, increased fatigue, hair loss, weight gain, cold intolerance, decreased sweating, galactorrhea, and puffiness. As reported by Patil et al. (2021) some hypothyroidism associated symptoms such as decreased sweating, cold intolerance, and puffiness rarely occur at the initial stages of the disease. The deficiency of thyroid hormone in blood stimulates the pituitary glands to produce thyroid stimulating hormones (TSH) as a compensatory mechanism.

This explains why people with hypothyroidism usually have elevated TSH levels. Iodine-associated hypothyroidism is associated with an enlargement of thyroid glands, a condition known as goiter, which occurs in addition to the other coming symptoms. Additional symptoms that are unique to autoimmune hypothyroidism/hashimoto disease are painless enlarged thyroids, fullness of throat, and episodic neck pains (Patil et al., 2021).

The subjective data of patient J. M. reveals that she has dry skin, increased fatigue, thinning, and weight gain. She is also at an increased risk of developing hypothyroidism due to her advanced age and amlodipine use. J. M. does not have an enlarged thryroid/ a swollen neck. Besides, she does not report episodic neck pains. Hypothyroidism is associated with significantly elevated levels of TSH in the blood and significantly reduced free T4 levels (Patil et al., 2021).

Her objective findings reveal significantly elevated TSH concentrations in the blood at a value of 23 against a reference range of 0.4-4.0 and significantly low free T4 results at a value of 0.05 against a reference range of 0.9-2.4. Besides, patients with hypothyroidism normally have significantly decreased concentrations of erythrocytes (RBCs) and Vitamin D in the blood (Wopereis et al., 2018; Ahi et al., 2020). Laboratory findings for patient J. M. revealed RBC concentration of 4.31 against a reference range of 135-146. Vitamin D level is 14 against a reference range of 36-114. These subjective and objective findings indicate that the most likely diagnosis for the patient is drug-mediated hypothyroidism.

P (plan)

Diagnostic studies:

• Evaluate the patient for the risk of developing autoimmune thyroid disease by measuring the levels of thyroid peroxidase antibodies (Patil et al., 2021).

Referrals to other health-care providers:

• J. M. has been referred to a primary care physician for detailed physiological assessment.

Pharmacological intervention:

• Levothyroxine monotherapy prescribed. This is the drug of choice for hypothyroidism. The appropriate dose recommended is 1.6 mcg/kg per day with two equal doses. The morning dose is taken 30-45 minutes before breakfast, whereas the night dose is taken at least 3 hours post-meal at bedtime (Patil et al., 2021)

Non-pharmacological interventions:

• Recommend foods rich in beans, peas, tuna, cheese, milk, aggs (Patil et al., 2021).

Patient education:

• J. M. has been advised to stop using amlodipine and evaluate after four weeks.
• She has been educated to take her medications as prescribed.
• The patient has been informed about the risk factors for hypothyroidism, how to avoid them, as well as the side effects of the prescribed drugs

Health promotion:

• J. M. has been advised to eat a balanced diet full of vegetables, fruits, peas, beans, cheese, and milk.
• An age-appropriate physical activity plan has been developed to help her keep fit and healthy.

Planned follow up visits:

• The patient has been informed to visit facility after four weeks for further evaluation.
• Contacts have been shared to facilitate communication in case problematic symptoms or drug side effects occur.

Reflection: The main lesson that I have learned from this case study is that patients might presents with symptoms that might resemble other diseases. For an appropriate treatment strategy to be chosen, it is advisable that the healthcare provider conducts a comprehensive assessment in order to make an accurate diagnosis. The patient’s primary diagnosis must be aligned with both subjective and objective findings.

 References

Ahi, S., Dehdar, M.R. & Hatami, N. (2020). Vitamin D deficiency in non-autoimmune hypothyroidism: a case-control study. BMC Endocrine Disordets 20, 41. https://doi.org/10.1186/s12902-020-0522-9

Patil, N., Rehman, A., & Jialal, I. (2021). Hypothyroidism. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519536/

Wopereis, D. M., Du Puy, R. S., van Heemst, D., Walsh, J. P., Bremner, A., Bakker, S., Bauer, D. C., Cappola, A. R., Ceresini, G., Degryse, J., Dullaart, R., Feller, M., Ferrucci, L., Floriani, C., Franco, O. H., Iacoviello, M., Iervasi, G., Imaizumi, M., Jukema, J. W., Khaw, K. T., … Thyroid Studies Collaboration (2018). The relation between thyroid function and anemia: a pooled analysis of individual participant data. The Journal of Clinical Endocrinology and Metabolism, 103(10), 3658–3667. https://doi.org/10.1210/jc.2018-00481