A 73-year-old retired anesthesiologist

Assessing, Diagnosing, and Treating Hematological and Immune System Disorders
Many factors affect patients’ hematological and immune status. Additionally, manifestations of these disorders may appear in different organ systems. As an advanced practice nurse, you must be able to diagnose and treat patients with hematological and immune status disorders by prescribing necessary treatments, assessments, and follow-up care.

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To prepare:
• Review the case study provided by your Instructor.
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Case to use

73-year-old with anemia and mild thrombocytopenia for five months.
Workup showed no evidence of blood loss. He is quite fatigued and has
lost weight. No fever, jaundice, pruritus, dark-colored urine, bleeding or
melena. He recently started taking Hyzaar, but he has had no other recent
medication changes.
PAST MEDICAL HISTORY:
1. Anemia and mild thrombocytopenia, both recently diagnosed.
2. History of atrial fibrillation.
3. Type 2 diabetes.
4. Hyperlipidemia.
5. Congestive heart failure.

MEDICATIONS:
1. Glyburide 5 mg twice daily.
2. Zocor 40 mg daily.
3. Digoxin 0.15 mg daily.
4. Hyzaar daily
SOCIAL HISTORY: He is a retired anesthesiologist, married, 3 children.
Former pipe smoker. Denies drinking
FAMILY HISTORY: A grandmother had type 2 diabetes. Father had
Parkinson disease and Mother died of old age at 84. A sister has asthma,
CHF and obesity.
REVIEW OF SYSTEMS: He feels tired and weak. He has chronic right
shoulder rotator cuff pain. No GU symptoms. He has had anorexia and a
15-pound weight loss over the last couple of months. He has shortness of
breath with light activity. He was treated for pneumonia in fall 2003. He
has atrial fibrillation, but no chest pain. No neurologic symptoms, rashes,
or emotional problems. Had trouble with blood sugar control recently,
metformin was discontinued.

PHYSICAL EXAMINATION: Somewhat obese. Not appearacutely ill. His
sclerae are anicteric. No palpable cervical, supraclavicular, axillary or
inguinal adenopathy. The heart rhythm is irregularly irregular. The lungs
are clear to auscultation. Abdomen is soft, nontender and nondistended.
Spleen is not palpable. The liver is palpable 1 to 2 fingerbreadths below
the costal margin. The extremities have trace edema. Neurologic exa

_______________________
Subjective:
The patient, a 73-year-old retired anesthesiologist, presents with complaints of anemia and mild thrombocytopenia that have been present for the past five months. He reports feeling fatigued and experiencing weight loss. He denies fever, jaundice, pruritus, dark-colored urine, bleeding, or melena. The patient recently started taking Hyzaar, but there have been no other recent changes in medications.

The patient’s past medical history includes atrial fibrillation, type 2 diabetes, hyperlipidemia, and congestive heart failure. His current medications include Glyburide 5 mg twice daily, Zocor 40 mg daily, Digoxin 0.15 mg daily, and Hyzaar. He is a retired anesthesiologist, married with three children, and used to be a pipe smoker but denies drinking alcohol. Family history reveals type 2 diabetes in the grandmother, Parkinson’s disease in the father, and CHF, asthma, and obesity in a sister.

On review of systems, the patient reports feeling tired and weak, chronic right shoulder rotator cuff pain, anorexia, and a 15-pound weight loss over the past couple of months. He experiences shortness of breath with light activity and has a history of pneumonia in fall 2003. He has atrial fibrillation but no chest pain, neurologic symptoms, rashes, or emotional problems. The patient also mentions recent trouble with blood sugar control, resulting in the discontinuation of metformin.

Objective:
Upon physical examination, the patient is somewhat obese but does not appear acutely ill. His sclerae are anicteric, and there are no palpable cervical, supraclavicular, axillary, or inguinal adenopathy. The heart rhythm is irregularly irregular, and the lungs are clear to auscultation. The abdomen is soft, nontender, and nondistended, with a liver palpable 1 to 2 fingerbreadths below the costal margin. Trace edema is noted in the extremities.

Assessment:
Based on the patient’s presentation, the following differential diagnoses are considered:

Iron deficiency anemia:

Diagnostic criteria: Microcytic anemia, low serum ferritin, low transferrin saturation.
Rule-in: Low hemoglobin and hematocrit, low serum ferritin, low transferrin saturation.
Rule-out: Normal iron studies, normal hemoglobin and hematocrit.
Pertinent positives: Fatigue, weight loss, anorexia, iron deficiency.
Pertinent negatives: No blood loss, no fever, jaundice, pruritus, dark-colored urine, bleeding, or melena.
Vitamin B12 deficiency anemia:

Diagnostic criteria: Macrocytic anemia, low serum vitamin B12 level.
Rule-in: Elevated mean corpuscular volume (MCV), low serum vitamin B12 level.
Rule-out: Normal MCV, normal serum vitamin B12 level.
Pertinent positives: Fatigue, weight loss, anorexia.
Pertinent negatives: No blood loss, no fever, jaundice, pruritus, dark-colored urine, bleeding, or melena.
Myelodysplastic syndrome (MDS):

Diagnostic criteria: Cytopenias (anemia and thrombocytopenia), dysplasia in bone marrow.
Rule-in: Persistent cytopenias, dysplasia in bone marrow.
Rule-out: Normal bone marrow, no cytopenias.
Pertinent positives: Fatigue, weight loss,