Hematological and Immune System Disorders

Posted: January 5th, 2023

Week 8: Hematological and Immune System Disorders

Author’s Name

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Week 8: Hematological and Immune System Disorders

Patient Description

The client, a 68-year-old woman

Subjective

CC: “I am increasingly becoming weak” 

HPI: comes to the office complaining of feeling tired, and a sense of being week. The patient also says that she sometimes encounters shortness of breath.

Current Medication: Other than high cholesterol level that she manages using Lipitor, the client has been healthy.

PMHx: Patient has been healthy.

Soc and Substance Hx: The patient leaves close to her children, but not in the same house. She has no history of substance use.

Fam Hx: Her husband died nine months ago.

Surgical Hx: Further examination reveals that she underwent appendectomy in childhood as well as a hysterectomy for uterine myoma a decade ago.

Mental Hx: The patient has not encountered any mental problem.

Violence Hx: The client has not experienced violence.

Reproductive Hx: Presently sexually inactive.

ROS:

General: The patient reports relentless fatigue, weakness, and hardship in breathing.

HEENT:

Eyes: No reported defection with vision.

Ears, nose, throat: No problem with hearing, sense of smell, and throat.

Skin: Conjunctiva pale

Cardiovascular: No recorded case of chest complications or pain, chest discomfort, or chest pressure. The patient does not depict any case of edema or palpitations.

Respiratory: Even though the patient does not show cases of sputum or cough he exhibits shortness of breath.

Gastrointestinal: No reported cause of nausea, vomiting, or diarrhea.

Genitourinary: No reported case burning sensation during the process of urinating.

Neurological: The patient does not report any case of numbness, paralysis, or adverse changes in bladder or bowel movement. Indeed, the patient’s abdomen is soft and bowel sounds are within normal range (bowel sounds × 4).

Muscoloskeletal: No muscle pain or stiffness.

Hematologic: No case of anemia or bleeding.

Lymphatics: The patient has not undergone splenectomy.

Psychiatric: No record of anxiety or depression.

Endocrinologic: No evidence of intolerance to heat or cold, and no case of polydipsia or polyuria.

Reproductive: No vaginal discharge, and no case of pregnancy in the recent past.

Allergies: No reported cases of drug allergic reactions.

O (Objective)

Physical exam: Physical examination of the patient reveals that the mucous membranes are moist, and shows a case of conjunctiva pale. However, the physical examination does not show any case of lymphadenopathy of femoral area or neck.

Diagnostic results: Vitals: Other checks of vital requirements are within normal range, including BP 106/70 mm Hg, respiratory rate 18 breaths/min, and HR 98 beats/min.

Dipstick Test – Performing a urine dipstick test to show the presence of abnormalities in the urine gives a negative result. The results show that the client does not contain adverse levels of components such as bilirubin, creatinine, glucose, protein, or calcium among other components in her urine, which could be an indication of further impurities in the blood (Hataysal, Saracligil, Dagi & Vatansev 2018

Colonoscopy – It emerged that the patient has a neoplasm in the colon, which means she has a cancerous tumor in the colon, which could be life-threatening (Granados-Romero, Valderrama-Trevino, Flores & Barrera-Mera 2017).

A (Assessment)

Differential diagnoses: The two diagnoses that are applicable in this case are urine dipstick test and colonoscopy.

• The urinalysis is essential because it helps to identify the presence of impurities in the blood that could make the client to witness the adverse effects.
• A colonoscopy, on the other hand, is imperative because it helps to understand whether the past surgical processes have any impact on the present situation.

P (Plan)

There are many treatment options for the cancer patients, and the approach would depend on the type and stage of growth. A possible treatment option for the patient is chemotherapy, which is offered as an infusion into a vein. The approach presents an opportunity to kill cancerous cells that might have spread through the body far away from the primary tumor. Nevertheless, the patient could experience side effects such as nausea, hair loss, loss of appetite, and fever (Aslam, Naveed, Ahmad & Abbas, 2014). In addition, the patient will follow a pharmacological plan that would help her manage the condition. Specifically, the client will use Avastin (Bevacizumab) that is approved by Food and Drug Administration (FDA) as an effective remedy for mCRC (metastatic colorectal cancer) (Devlin, Denson & Whitford, 2017).

The intervention plan relies on the guidance of various resources to achieve successful results. The intervener will seek the views of other practitioners, and will acquire information from various print and online sources on how best to approach the condition. The interaction will provide tips on how to perform the urinalysis and the colonoscopy, as well as give valuable information regarding the possible impact of the adopted treatment methods.

Reflection

The study provides valuable information regarding ways of identifying a patient’s problem and recommending the best treatment plan. The case study shows the need to be very careful when diagnosing the issue by relying on what the patient says, and using the test findings to recommend the most suitable treatment option. I learn the importance of acquiring a wide range of information from others to make informed decisions.

References

Aslam, M., Naveed, S., Ahmad, A., & Abbas, Z. (2014). Side effects of chemotherapy in cancer patients and evaluation of patients opinion about starvation bases differential chemotherapy. Journal of Cancer Therapy, 5 (5), 817-822. doi:10.4236/jct.2014.58089

Devlin, E., Denson, L., & Whitford, H. (2017). Cancer treatment side effects: A meta-analysis of the relationship between response expectancies and experience. Journal of Pain and Symptom Management, 54 (2), 245-258. https://doi.org/10.1016/j.jpainsymman.2017.03.017

Granados-Romero, J., Valderrama-Trevino, A., Flores, E., & Barrera-Mera, B. (2017). Colorectal cancer: A review. International Journal of Research in Medical Sciences, 5 (11), 4667-4676. doi:10.18203/2320-6012.ijrms20174914

Hataysal, E., Saracligil, B., Dagi, H., & Vatansev, H. (2018). How accurate is the urine dipstick test for diagnosing urinary tract infection? The European Research Journal 3, 1-5. doi:10.18621/eurj.406215