SOAP Note Template:
Subjective:
Mrs. Derrick is a 78-year-old female presenting with complaints of increasing symptoms of lethargy, fever, night sweats, a 15 lb. weight loss over 6 months, bleeding gums when brushing her teeth, purplish patches in the skin, and shortness of breath. She reports a sensation of deep pain in her bones and joints. She has a 15-year history of working at a dry-cleaning shop, with exposure to dry cleaning chemicals, which are known to be a possible cause of leukemias.
Objective:
Physical examination reveals enlarged lymph nodes and swelling or discomfort in the abdomen.
Assessment:
Based on the patient’s symptoms and physical examination findings, a diagnosis of acute lymphoblastic leukemia (ALL) is made.
Plan:
1. Additional history: Further exploration of the patient’s past work environment is necessary to gather information on specific dry cleaning chemicals she was exposed to, duration and intensity of exposure, and any other potential occupational hazards.
2. Additional objective data: In addition to the physical examination findings, the patient’s complete blood count (CBC) and peripheral blood smear should be assessed for abnormal cell counts and morphological changes. A bone marrow biopsy should also be considered to evaluate the presence of leukemic cells in the bone marrow.
3. Lab tests: Four lab tests that should be ordered include:
a. Complete blood count (CBC): This test will provide information on the patient’s red blood cell count, white blood cell count, and platelet count. Abnormal cell counts can be indicative of leukemia.
b. Peripheral blood smear: This test will examine the morphology and characteristics of the patient’s blood cells. Abnormal cell morphology, such as the presence of blast cells, can suggest leukemia.
c. Bone marrow biopsy: This test will involve obtaining a sample of the patient’s bone marrow to assess for the presence of leukemic cells. This is essential for confirming the diagnosis of ALL.
d. Flow cytometry: This test uses antibodies to identify different cell types in the bone marrow. It can help determine the subtype of ALL based on the expression of specific markers.
4. Differential diagnoses: Two differential diagnoses to consider in this case are:
a. Multiple myeloma: This is a malignancy of plasma cells that can present with similar symptoms, such as bone pain, fatigue, weight loss, and abnormal blood counts.
b. Non-Hodgkin lymphoma: This type of lymphoma can also present with enlarged lymph nodes, discomfort in the abdomen, and constitutional symptoms like fever and night sweats.
5. Diagnostic tests to confirm ALL diagnosis:
a. Cytogenetic analysis: This test examines the chromosomes of leukemic cells to identify specific genetic abnormalities, such as chromosomal translocations, which are common in ALL.
b. Immunophenotyping: This test uses antibodies to identify cell surface markers, allowing for further characterization of leukemic cells. It can help confirm the diagnosis and determine the subtype of ALL.
6. Consultation: It would be prudent to refer the patient to a hematologist-oncologist for further evaluation and management of ALL. The expertise of a specialist in the field will ensure appropriate treatment and monitoring of the patient’s condition.
In conclusion, for Mrs. Derrick with suspected ALL, additional history regarding her past work environment, further objective data including various lab tests, consideration of differential diagnoses such as multiple myeloma and non-Hodgkin lymphoma, and diagnostic tests to confirm ALL diagnosis, specifically cytogenetic analysis and immunophenotyping, are necessary. Referral to a hematologist-oncologist for consultation is also recommended.
