Assessing, Diagnosis, and Treating Hematological and Immune System Disorders Essay

Assessing, Diagnosis, and Treating Hematological and Immune System Disorders Essay

Focused SOAP Note Template

Patient Information:

Initials: Mrs. L.

Age: 68

Sex: Female

Race: White

S (subjective)

CC (chief complaint): Feeling tired all the time and now, more recently, feeling weak and like “I can’t catch my breath my breath sometimes.”

HPI (history of present illness): Mrs. L is a 68-year-old white female who has presented to the clinic for evaluation with complaints of feeling weak all the time and now. She reports that she has been feeling weak since recently and that she cannot catch her breath sometimes. She cites that she has been healthy all along except for her high cholesterol, which is managed with Lipitor. Her husband died nine months, and she thinks her fatigue would be attributed to his death, but she is worsening and not getting better as time passes.

Current Medications: Lipitor only for high cholesterol.

Allergies: No food or drug allergies.

PMHx: She has high cholesterol.

Soc and Substance Hx: Not provided.

Fam Hx: She has two daughters living nearby.

Surgical Hx: She had an appendectomy in her childhood and a hysterectomy for uterine myoma ten years ago.

Mental Hx: Anxiety.

Violence Hx: None stated. 

Reproductive Hx: She is postmenopausal. She had a hysterectomy for uterine myoma ten years ago.  

ROS (review of symptoms):

GENERAL: She has lost 10 pounds in nine months.

HEENT:

• Eyes: Ho vision loss, double vision, or eye pain.
• Ears, Nose, Throat: No hearing loss, tinnitus, epistaxis, or sore throat.

SKIN: No itchiness.

CARDIOVASCULAR: No chest pain or palpitations.

RESPIRATORY: Endorses shortness of breath.

GASTROINTESTINAL: Denies nausea/vomiting.

GENITOURINARY: None listed.

NEUROLOGICAL: No reported headache.

MUSCULOSKELETAL: No reported muscle or bone pain.

HEMATOLOGIC: Has anemia. No bleeding tendencies.

LYMPHATICS: No lymph node enlargement.

PSYCHIATRIC: Anxiety.

ENDOCRINOLOGIC: No polyuria, polyphagia, or heat/cold intolerance.

REPRODUCTIVE: No discharge.

ALLERGIES: None listed.

O (objective)

Physical exam:

Vital signs: Blood pressure 106/70mmHg, Heart rate 108 (regular rhythm), Respiratory rate 18, Temperature: afebrile, Body mass index (BMI): 22.

GENERAL: She is a slender, quiet-spoken old woman who appears tired.

HEENT: Conjunctiva is pale, and the mucous membranes are moist.

CARDIOVASCULAR: Tachyarrhythmia of the heart with a regular rate, soft mid-systolic murmur auscultated.

RESPIRATORY: Bilateral air entry, chest clear on auscultation.

GASTROINTESTINAL: The abdomen is soft, bowel sounds ×4

Diagnostic results:

Urine dipstick is negative.

A colonoscopy shows a neoplasm in the colon.

A (assessment)

Additional Subjective Data.

I am interested in finding out for how long she had the above symptoms. Has her symptoms been worsening? If she has any history of cigarette smoking or alcohol consumption. What does her dietary intake involve, red meat, low/high fiber foods, processed food, or animal fats? Has she been screened or diagnosed with colorectal or any cancer? Is there any history of colorectal cancer in her family? Has she ever been diagnosed or on treatment for any inflammatory bowel disease? Has she observed any changes in her bowel patterns? Any changes in her stool if it contains blood, any changes in its color, or rectal bleeding. Any recent weight loss. Any abdominal pain.

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Additional Objective Data.

Changes in bowel patterns, e.g., diarrhea, constipation, or bloody stool

Abdominal tenderness, cramping, or flatus

Rectal bleeding.

Medical History

Any significant findings of medical conditions from both her mother and father’s side, any history of relatives diagnosed with cancer and the age they were diagnosed, the reason for any deaths that have been witnessed, any allergies, and social history comprising alcohol intake and cigarette smoking.

Tests to Order 

Complete blood count (CBC): This is a baseline test to evaluate the patient’s hemoglobin, hematocrit, and red blood cell level. This will help determine if the patient is anemic and the type of anemia the patient has, if microcytic, normocytic, or macrocytic.

Fecal occult blood test (FOBT). This test aims to assess hidden (occult) blood in the stool (Kaur & Adamski, 2020). The occult blood would be due to bleeding along the gastrointestinal tract due to ulceration of a mass or any related pathology. Kaur & Adamski (2020) states that FOBT is most commonly used to screen for colorectal carcinoma; therefore, it is needed in this patient.

Double-contrast barium enema. A tube is introduced through the anal orifice, and dilute barium is infused until it reaches the terminal ileum. Plain radiography of the abdomen is then taken. A follow-through of the barium is followed, and areas of low uptake are noted. This region presenting as constriction would be due to a suspicious mass.

Endorectal ultrasound. This is a rapid imaging modality to detect any mass within the colon or rectum.

A repeat colonoscopy/sigmoidoscopy can be ordered, as well as a virtual colonoscopy, where a CT scan is used to reconstruct a 3-D image of the inner surface of the colon (Dariya et al., 2020).

Tumor markers: carcinoembryonic antigen (CEA), CA19-9. CEA is an oncofetal antigen that is elevated in cancers such as colorectal cancer (Jelski & Mroczko, 2020). CA 19-9 is a carbohydrate antigen marker synthesized by epithelia such as the colon (Jelski & Mroczko, 2020). Elevation of the markers may be indicative of a malignancy somewhere.

Metastatic workup. This involves imaging modalities like abdominal pelvic ultrasound to check for metastasis to the bladder or cervix. A chest radiograph can rule out any metastasis to the lungs. Abdominal CT scan to detect metastasis to the liver.

Differential Diagnosis 

Colon cancer

Refers to cancer of the large intestines. It is a common and lethal disease. It affects older people, and about 90% of the cases are observed in patients above the age of 50 years (Recio-Boiles et al., 2019). Before the onset of the carcinoma, adenomas develop with the lumen of the colon. Risk factors of colon cancer include family history, advancing age, male gender, diet with lower fiber component and rich in animal proteins, bacterial infections, smoking, alcoholism, diabetes, obesity, and exposure to some viruses (Recio-Boiles et al., 2019). Patients will report hematochezia, melena stool, abdominal pain, change of bowel habits, fatigue, weakness due to anemia, weight loss associated with advancing age, and tenesmus. Right-sided colonic tumors are associated with bleeding, and they cause anemic symptoms among patients compared to left-sided tumors. Upon examination, patients may have the following signs: anemia, lymphadenopathy, jaundice, palpable abdominal mass, and a rectal mass. Diagnosis is by doing a colonoscopy or sigmoidoscopy, which is 94% sensitive (Dariya et al., 2020). Colon cancer is my most appropriate diagnosis for the patient because of the positive finding of doing a colonoscopy and finding a mass. She also has signs of anemia which would be due to hemorrhage happening because of a bleeding lesion or burden of the tumor.

Inflammatory bowel disease (IBD)

Refers to chronic inflammation of the gastrointestinal tract due to disordered immune response towards gut microflora. IBD involves two entities, namely Crohn’s disease and ulcerative colitis (McDowell et al., 2020). Ulcerative colitis involves diffuse colonic mucosa inflammation and mainly involves the rectum but may extend to the sigmoid up to the cecum (McDowell et al., 2020). Crohn’s disease, on the other hand, causes transmural ulceration of any portion of the gastrointestinal tract, and it mostly affects the terminal ileum and colon (McDowell et al., 2020). Patients with ulcerative colitis will present with bloody diarrhea, tenesmus, the sensation of incomplete evacuation, and abdominal pain. For Crohn’s disease, patients will have pain involving the lower quadrant, weight loss, and non-bloody diarrhea. Diagnosis is based on a combination of clinical findings, inflammatory markers, imaging findings, and biopsy results (McDowell et al., 2020). A complete blood count will show anemia, while through endoscopy, a biopsy can be obtained to make a diagnosis.

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Plan of Care

Mrs. L should be admitted and stabilized by correcting her anemia with a blood transfusion or iron supplements, depending on the severity of her anemia. Since she seems anxious, she should be on antidepressants or benzodiazepines to control her anxiety. Her nutrition should be supported since she has a pathology involving the gastrointestinal tract. She should receive analgesia for pain, fluids to correct dehydration, achieve electrolyte balance, and provide emotional support and postoperative care. Preparations for surgery include laxatives to prepare the bowel, maintaining the patient nil per oral, prophylactic antibiotics, and monitoring urine output (Shinji et al., 2022). Diagnostic tests to evaluate the cause of her condition include taking a biopsy during colonoscopy from the mass found within the colon and histologically examining it to see if it is malignant. CEA antigen will also be measured, and if elevated, the likelihood that the mass is colon cancer will be high. A stool for occult blood is also necessary for and colonoscopy (Kaur & Adamski, 2020).

P(plan)

Treatment Plan

Colon Cancer 

Surgery is the mainstay treatment for colon cancer (Shinji et al., 2022). However, this depends on the stage of the cancer. It can be combined with chemotherapy, radiotherapy, or both. Before surgery, the patient should receive pre-operative care that entails correcting anemia, nutrition support, and antibiotics. Depending on the position of the tumor, surgical options include right/left hemicolectomy.

IBD

Supportive care, 5-aminosalicylic acid, corticosteroids, or surgery (McDowell et al., 2020).

Referrals

Gastroenterologist, general surgeon, oncologist, pathologist

Education. 

Inform her that she probably has a tumor that should be ruled out and counsel her appropriately.

Follow-up

This should be done after going to all referrals.

Reflection

This is a case where this patient is most likely to have colon cancer. Her presentation is relevant to features associated with colon cancer on the right side. Since the death of her husband, she has been feeling fatigued and thought this would be because of his death. However, upon presenting to the clinic and a colonoscopy being done, a mass is noted in her colon. I am interested in knowing much about her history, especially her family history, if there is a history of cancer. It will be essential to have a biopsy taken and staging of the mass done to determine her effective treatment plan. I will counsel her on her probable diagnosis and tell her she has a high likelihood of having surgery and may require a stoma.

References

Dariya, B., Aliya, S., Merchant, N., Alam, A., & Nagaraju, G. P. (2020). Colorectal Cancer Biology, Diagnosis, and Therapeutic Approaches. Critical Reviews^TM in Oncogenesis, 25(2), 71–94. https://doi.org/10.1615/critrevoncog.2020035067

Jelski, W., & Mroczko, B. (2020). Biochemical Markers of Colorectal Cancer – Present and Future. Cancer Management and Research, 12, 4789–4797. https://doi.org/10.2147/cmar.s253369

Kaur, K., & Adamski, J. J. (2020). Fecal Occult Blood Test (Hemoccult). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537138/

McDowell, C., Farooq, U., & Haseeb, M. (2020). Inflammatory Bowel Disease (IBD). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470312/

Recio-Boiles, A., Waheed, A., & Cagir, B. (2019, June 3). Colon cancer. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470380/

Shinji, S., Yamada, T., Matsuda, A., Sonoda, H., Ohta, R., Iwai, T., Takeda, K., Yonaga, K., Masuda, Y., & Yoshida, H. (2022). Recent Advances in the Treatment of Colorectal Cancer: A Review. Journal of Nippon Medical School, 89(3), 246–254. https://doi.org/10.1272/jnms.JNMS.2022_89-310

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Week 8: Hematological and Immune Disorders

Week 8 Case 1: Anemia in Older Adult-(Last name beginning A-M)

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) 108 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:

What additional subjective data are you seeking?

What additional objective data will you be assessing for?

What medical history would you obtain from the patient? List at least three.

What tests will you order? Describe at least four lab tests.

What are the differential diagnoses that you are considering? Describe two.

What is your plan of care? List at least two diagnostic tests you will order to evaluate the cause of her condition.

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 healthcare 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.