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The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
Week 8 Case 2: Acute Lymphoblastic Leukemia (ALL)
CC: Mrs. Derrick is a 78-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 states that she has had sensation of deep pain in her bones and joints.
She notes that her employment history includes working at a dry-cleaning shop for 15 years, with an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias)
PE shows enlarged lymph nodes and swelling or discomfort in the abdomen.
You diagnose this patient with acute lymphoblastic leukemia (ALL).
Address the following in your SOAP note:
What additional history about her past work environment would you explore?
What additional objective data will you be assessing for?
What tests will you order? Describe at least four lab tests.
What are the differential diagnoses that you are considering? Describe two.
List at least two diagnostic tests you will order to confirm the diagnosis of ALL.
Will you be looking for a consultation? Please explain.
As the primary care provider for this patient with ALL:
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