NUR 6540 LEUKEMIA SOAP NOTE 2022/2023

NUR 6540 LEUKEMIA SOAP NOTE 2022/2023 Hematology SOAP Note Sabrina K Master of Science in Nursing, Walden University NRNP 6540: Advanced Practice Care of Older Adults Dr. Donna Petko Patient Information: Initials: __D Age: 78 Sex: F Race: not documented S CC: lethargy HPI: Patient is 78 yo female who comes in for increase symptoms of lethargy, fever, night sweats, a 15lb weight loss over 6 months, bleeding gums when she brushes her teeth. She also has purplish patches on her skin, has episodes of shortness of breath and has a deep pain in her bones and joints. Patient has had exposure to benzenes, worked at a dry-cleaning shop for 15 years. Other questions I would ask her about: 1. Any recent infections? 2. Past medical history? Any inherited or familial risk factors to ALL? 3. Any family hx that has ALL? 4. any exposure to pesticides and herbicides during childhood? Current Medications: not documented Allergies: not documented PMHx: not documented Fam Hx: not documented Social hx: history of working a dry-cleaning shop for 15 years, + exposure to benzenes. No documentation of tobacco or cigarette use Complete ROS: General: c/o weight loss, and lethargy. Denies chills and fever HEENT: no visual loss, blurred vision, runny nose, ear pain, dysphagia. C/o bleeding gums Resp: no cough. C/o shortness of breath Cardio: no chest pain, palpitations, or edema GI/GU: denies n/v/d Neuro: no headache, dizziness, tremors MSK: no joint pain Skin: no rash/itch