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Many factors affect patients’ hematological and immune status, and because blood and lymph circulate throughout the body, manifestations of these disorders may appear in different organ systems (Kennedy-Malone et al., 2019). Patients with such disorders often have complex health issues and need long-term, ongoing care. Older adult patients may be especially vulnerable due to age-related immune-system response.
This week, you explore geriatric patient presentations of hematological and immune system disorders. You also examine assessment, diagnosis, and treatment for these disorders and complete a SOAP note.
Learning Objectives
Students will:
Evaluate patients presenting with hematological or immune system disorders
Develop differential diagnoses for patients with hematological or immune system disorders
Develop appropriate treatment plans, including diagnostics and laboratory orders, for patients with hematological or immune system disorders
Analyze the diagnosis and treatment of hematological or immune system disorders
CASE STUDY WEEK EIGHT
Posted on: Monday, October 17, 2022 12:31:37 AM EDT
Week 8 Case 2: Acute Lymphoblastic Leukemia (ALL)
You are a nurse practitioner staffing a community geriatric primary care clinic staffed with physicians and nurse practitioners and interdisciplinary professionals, with full laboratory and radiology services. You anticipate next a new patient when a frail-looking woman is escorted in by a medical assistant, appearing too weak to continue walking unassisted and appearing to be struggling to breathe more than short, quick breaths as if she has been experiencing some strenuous activity. The MA tells you that she came by taxi, the driver assisted her into the clinic. She told the MA that she was “feeling worse after the hustle of getting dressed and to the clinic.” A usual day is to be at home in her small apartment where she says everything is in easy reach; the shower is easier to manage since she got a bench to sit in the shower. And this weakness has persisted for over 3 months despite eating lots of protein and vegetables delivered to her at home and getting a lot of rest. The MA checks her oxygen and begins oxygen by cannula at 3L/minute as the patient insists on speaking, obviously anxious and worried. CC: Mrs. Derrick is an 80-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 agrees to her earlier statement as you repeat what she said as she arrived. In addition, she states that she has had sensation of deep pain in her bones and joints. The pain is relieved by Tylenol and does not keep her awake if she takes Tylenol at bedtime. She reports a neighbor has had a cold but other she has been around has have not told her they are sick. She lives in a senior housing, rent controlled, apartment, where there are 5 floors of older adults. She attended sponsored activities until about a month ago but has not left her apartment since then due to lack of energy to participate. She has groceries delivered to her apartment. Family History- Parents both died of strokes at age 90 and 91. No siblings.
Social History-
She is single, never married, no children. She worked since graduation from high school as a secretary at a few different places and retired at age 65 with Social Security payments and a small pension each month. She notes that her employment history includes working at a dry-cleaning shop for the last 15 years of her employment, and years later, watching the TV News, that she could have had an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias)
Medical History-
No medications except multiple vitamins and the Tylenol every 4 hours if needed. No surgeries, no hospitalizations. She has been going for a checkup every two years to a private office but since she was always healthy, she did not make an appointment this year. She receives all flu shots from a home health agency at her apartment building and she has had the new shingles shot and a pneumonia shot. She has not had a tetanus shot as long as she can remember. She wears glasses that she gets at Wal-Mart every 2 years. Her hearing is checked at each clinic appointment, every 2 years.
PE is normal for the age of an 80-year-old except there are molar carries, enlarged lymph nodes and swelling or discomfort in the abdomen and both groins.
Your working diagnosis for this patient is acute lymphoblastic leukemia (ALL).
Based on that diagnosis, address the following in your SOAP note:
What effect on her health might social determinants of health have had? Is there additional information you would need to determine if an infection is present? Is there likely an infection that could have caused her symptoms and the signs you discovered on PE? Would you order a test to verify? Why would an infection need to be considered? What additional history about her past work environment would you have explored?
What tests would you have ordered initially? Describe at least four tests.
What other differential diagnoses were you considering? Describe at least two.
List at least two diagnostic tests you would have ordered to confirm the diagnosis.
Would you have been looking for a consultation? Please explain.
Will you be adding referrals form the interprofessional team at your primary care clinic? Who would be at the clinic for referrals? While the patient is in radiology you begin to consider one provisional diagnosis, ALL. She is surely in a weakened condition. You consider a plan for that. What would be the options? What would be your plan, in consideration of the status she described as you met her? As the primary care provider for a patient with ALL:
Describe the education and follow-up you will provide to this patient during and after treatment by the hematologist-oncologist.
Describe any medications or treatments that the PCP may consider while she is under the care of the hematologist-oncologist? Are there follow-up tests and exams that the PCP may consider based on typical side effects of chemotherapy? Describe at least three (3) roles as the PCP for the ongoing care of the ALL patient.
Is it likely that this patient will be able to live at home in her apartment during or following her treatment? How will you determine that?
If she needs ongoing care, how and with whom will you determine a referral? How will social determinants of health enter into your overall assessment, initial plan, and follbciow up plan of care?
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