Case Study

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.

Be sure to include the diagnosis, differential diagnosis, pathophysiology, epidemiology, physical exam findings, diagnostic testing any needed referrals, management plans, patient education and follow-ups. Please submit to dropbox by the assigned due date.

  1. What is diagnosis?
  2. List 3 differential diagnosis (rule out by physical exam, diagnostic testing and/or labwork).
  3. Discuss the pathophysiology, epidemiology and risk factors for the diagnosis.
  4. Is there any other diagnostic testing that you would like to perform?
  5. Is there a relationship between Candy’s change in school performance and her diagnosis?
  6. Discuss the relationship between the symptoms and the diagnosis.
  7. Discuss the significance of the laboratory values.
  8. Discuss the cause and effect relationship between Candy’s level of growth and development and her diagnosis.
  9. What other data would be helpful for the nurse practitioner to have?
  10. What are the priorities of care for Candy?
  11. What pharmacological and not pharmacological education would you give to this patient and her father?
  12. What other responsibilities should the nurse practitioner delegate to Candy and her father?

 

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-

KAPLAN SCHOOL OF NURSING


SOAP NOTE/CASE STUDY GRADING RUBRIC

[100 Points Total]

A. Project Content

80 points possible



0

1-5

6-10

11-15

16-20

Score

Presentation of Case, subjective and

No paper submitted

Needs improvement

Partially addressed case and/or Subjective Data. Only 4-6 components addressed.

Partially addressed Case and/or Subjective Data.

Only 7-9 components addressed.

Clearly and thoroughly presents Case and Subjective Data.

All 10 components addressed

20

Objective Data

No Paper submitted

Omitted 5 or more components of the objective data

Omitted 3-4 components of the objective data

Omitted 1-2 components of the objective data

Clearly and thoroughly presents Objective Data. All of the relevant systems addressed based on the CC and HPI

20

Assessment

No Paper submitted

Failed to address the diagnosis and/or differential diagnosis

Diagnosis incorrect but completed a thorough exam and lab work in order to rule in diagnosis

Diagnosis correct but failed to rule in diagnosis with exams or lab work or other testing in detail.

Correct Differential and Medical diagnosis

20

Plan

None of the components were addressed

1 to 2 of the components addressed

Three to 5 components addressed

Correct plan of care. Only 6-7 components addressed

Correct plan of care. Thoroughly addressed

(diagnostic studies, meds, education, health promotion,

Developmental stages, Ethical and cultural considerations, follow up, referrals). All 8 components addressed

20



Total Points

___/80







A. Project Content Points)



B. Organization and Formatting

11points possible

0

0

1-8

SOAP NOTE 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.

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)

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.  

1.

2.

3.

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

 

1.

PLAN

A: Orders

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided

2. Diagnostic testing

3. Problem oriented education

4. Health Promotion/Maintenance Needs

5. 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)