NRNP 6540 ADVANCED PRACTICE CARE OF OLDER ADULTS (HEMATOLOGICAL AND IMMUNE SYSTEM DISORDERS) WALDEN UNIVERSITY

NRNP 6540 ADVANCED PRACTICE CARE
OF OLDER ADULTS (HEMATOLOGICAL
AND IMMUNE SYSTEM DISORDERS)
WALDEN UNIVERSITY
lOMoAR cPSD|42147428
Focused SOAP Note: Hematologic
Subjective
Patient Information: Mrs. Derrick, 78-Year-Old, White, Female
CC (chief complaint): Mrs. Derrick came into the clinical with complaints of deep pain in her bones and
joints.
Location: Joints/ Joint pain
HPI (history of present illness): Mrs. Derrick is a is a 78-year-old, Caucasian, female who presents to
the clinic today with c/o increasing symptoms of lethargy, fever, and night sweats, and a 15 lb. weight loss
over 6 months. Additionally, Mrs. Derrick reports that her gums bleed when she brushes her teeth and
purplish patches in the skin. Furthermore, Mrs. Derrick reports that she has experienced shortness of
breath and that she has had sensation of deep pain in her bones and joints.
• Onset: 6 months ago
• Character: Deep sensation
• Associated signs and symptoms: lethargy, fever, bleeding of gums, purple patches in skin
Current Medications: Multivitamin
Allergies: NKDA. No known food or environmental allergies.
PMHx: Immunization Status-unknown.
Soc and Substance Hx: Mrs. Derrick is a 78-year-old female whose employment history includes
working at a dry-cleaning facility for 15 years. Lives alone. Unknown tobacco, alcohol, and drug use.
Fam Hx: Unknown
Surgical Hx: Unknown