Case Study 8

Unit 8 Hematology SOAP Note/Case Study Written Guide

Hematology Case study

Candy is a 13 year old who lives with her father and younger sister. Her mother died when Candy was 6 years old and her sister was 4 years old. Her father works a 12 hour shift full time to support himself and his daughters, and Candy makes sure she and her sister get to school each morning, take care of the house after school, and prepare their father’s dinner so he can eat as soon as he gets home from work. All three are very close and on his days off, Candy’s father is very devoted to his children. Candy began her menses when she was 11 years old and experiences regular periods every 28 days. She has excelled in school, being on the honor rolls consistently for the past 3 years. The past semester Candy’s school performance began to decline and she has been complaining of being tired “all of the time.” Her father notes that Candy “looks pale” and makes an appointment for Candy to be seen at the clinic.

At the clinic, the nurse practitioner performs a nursing history during which Candy’s father shares the observations he has made and Candy verifies the information. The nurse practitioner’s assessment reveals Candy is a clean, appropriately dressed, pale adolescent who appears fatigued. Candy’s vital signs are:

Temperature: 35.9 C (96.6 F)

Pulse: 116 beats/minute

Respirations: 30 breaths/minute

Blood pressure: 90/60

Candy’s lab values are:

Hemoglobin: 10 g/dL

Hematocrit: 28%

Total Iron Binding Capacity (TIBC): 450 mg/dL

Serum iron: 35 microgram/L (Broyles, 2006). You will need to answer the following questions and summarize in 1-2 paragraphs.

Create a Plan of Care for the assigned Hematology Case. Address the subjective and objective data by creating an assessment and plan of care for the patient. Please use the Template provided for you.

SOAP Note/Case Study TEMPLATE

Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis. Support your work with references that are within 5 years. References should only come from textbooks, journal articles or evidenced based websites (ex: CDC, NIH, ADA, etc.)

Subjective Data

Chief Complain (CC):

History of Present Illness (HPI):

Last Menstrual Period (LMP- if applicable)

Allergies:

Past Medical History:

Family History:

Surgery History:

Social History (alcohol, drug or tobacco use):

Current medications:

Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI). Only review the systems that are relevant to the chief complaint and HPI

Objective Data

Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.

Vital Signs/ Height/Weight:

General Appearance:

HEART:

RESP:

Assessment

A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.  Support your work with references

1.

2.

3.

B: Medical Diagnosis Please provide rationale Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis. Support your work with references.

 

1.

PLAN

A: Orders

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided. (If the patient is currently on a medication please list them and include the same information)

2. Mechanisms of action for each medication prescribed and current medications.

a. For all medications please include the above in addition to the Mechanisms of action, patient teaching

3. Diagnostic testing

4. Problem oriented education

5. Ethical and cultural consideration

6. Health Promotion/Maintenance Needs

7. Developmental stage

8. Referrals

B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)