Hematology SOAP Note
Sabrina K
Master of Science in Nursing, Walden University
NRNP 6540: Advanced Practice Care of Older Adults
Dr. Donna Petko
April 25th, 2021
This study source was downloaded by 100000832361371 from CourseHero.com on 04-25-2022 08:37:17 GMT -05:00
https://www.coursehero.com/file/97500575/N6540-leukemia-soap-notedocx/
, 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
O
This study source was downloaded by 100000832361371 from CourseHero.com on 04-25-2022 08:37:17 GMT -05:00
https://www.coursehero.com/file/97500575/N6540-leukemia-soap-notedocx/
Sabrina K
Master of Science in Nursing, Walden University
NRNP 6540: Advanced Practice Care of Older Adults
Dr. Donna Petko
April 25th, 2021
This study source was downloaded by 100000832361371 from CourseHero.com on 04-25-2022 08:37:17 GMT -05:00
https://www.coursehero.com/file/97500575/N6540-leukemia-soap-notedocx/
, 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
O
This study source was downloaded by 100000832361371 from CourseHero.com on 04-25-2022 08:37:17 GMT -05:00
https://www.coursehero.com/file/97500575/N6540-leukemia-soap-notedocx/
