Posted: July 7th, 2022

HPI: A 77-year-old woman with myelofibrosis NURS-6540

NURS-6540 Adv Pract Care Older Adults – Spring 2023

April 8, 2023

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Focused SOAP
Patient Information: BM, 77-year-old, Female, Caucasian

S
CC (Chief Complaint): Palpitations started this morning.

HPI: A 77-year-old woman with myelofibrosis, which was diagnosed on bone marrow biopsy on 8/22/22 and was concerning for post-thrombocythemia myelofibrosis, presented to the ED for a repeat bone marrow test and initiation of treatment. However, this morning, she reported palpitations and a fast heartbeat. Since her last blood transfusion on 2/17/23, her symptoms of fatigue, dyspnea with exertion, and sedentary behavior have been progressively worsening. She has lost 30 pounds in the past 6 months without trying, and she has been feeling cold even on warm days. Additionally, she developed diffuse eczema and was supposed to start Dupixant therapy, but the medication has not yet been delivered. She complains of palpitations but denies chest pain. She reports that she scratches her skin, which leads to petechial changes but no bruising. She denies diarrhea, dysuria, changes in taste or smell, night sweats, and nightmares.

Current Medications:
Multivitamin daily
Losartan 50mg daily
Fish Oil 1 tablet daily
Metformin 500mg BID

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Allergies: Atorvastatin, rash

PMHx: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis. She is up to date with childhood vaccinations, including Tetanus and MMR. She received a booster dose of her Covid Vaccine and is up to date with her flu vaccine.

Soc and Substance Hx: The patient lives with her son and verbalizes that she feels safe and well-cared for at her house. She denies any history of smoking or recreational drug use. She also denies any problems with eating.

Fam Hx: Father died at age 67 with Hypertension. Mother, died 65, with High cholesterol. Brother aged 58 with Hypertension and High cholesterol. Sister, died at 55, with CVA.

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Surgical Hx: Appendectomy, Abdominal hysterectomy, Bone marrow biopsy, Bilateral breast reduction, Cholecystectomy, Foot joint operations.

Mental Hx: She denies anxiety and depression. She denies any history of self-harm practices or suicidal and homicidal ideation.

Violence Hx: She denies any problems or history with personal safety. She feels safe living at home and in the community, and she has no issues with sexual violence.

Reproductive Hx: Post-menopausal. Denies use of contraceptives.

ROS:
• GENERAL: Verbalizes weight loss, weakness, and easy fatiguability. No fever or chills.
• HEENT: Head: Denies headache. Eyes: Denies blurred or double vision or pain or redness. Ears: Denies pain or decrease in hearing. Nose: Denies runny nose, blockage, or bleeding. Throat: Denies sore throat.
• SKIN: Complains of scattered and diffuse large patches of papular eruptions with rough bases and evidence of excoriations over trunk and limbs.
• CARDIOVASCULAR: Complains of irregular or rapid heartbeat. Denies chest pain or edema in upper and lower extremities.
• RESPIRATORY: Denies shortness of breath, dyspnea on exertion, cough, and
sputum production.
• GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, constipation, or diarrhea.
• GENITOURINARY: Denies dysuria, hematuria, or changes in urinary frequency or urgency.
• MUSCULOSKELETAL: Denies joint pain, stiffness, or swelling.
• NEUROLOGICAL: Denies changes in sensation, coordination, balance, or memory loss.
• PSYCHIATRIC: Denies anxiety, depression, or any changes in mood or behavior.
• ENDOCRINE: Reports a history of diabetes and denies any symptoms of hypoglycemia or hyperglycemia.
• HEMATOLOGICAL/LYMPHATIC: Reports a history of myelofibrosis and reports fatigue, easy fatiguability, and petechial changes in the skin.
• IMMUNOLOGICAL: Reports a history of allergic rhinitis and denies any new allergies or symptoms of an allergic reaction.

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O
Vital Signs:
• Blood pressure: 132/80 mmHg
• Heart rate: 110 bpm
• Respiratory rate: 18 bpm
• Oxygen saturation: 96% on room air
• Temperature: 98.6°F

Physical Exam:
• General: Appears tired and weak.
• Skin: Scattered and diffuse large patches of papular eruptions with rough bases and evidence of excoriations over trunk and limbs.
• Cardiovascular: Irregularly irregular rhythm with no murmurs, rubs, or gallops. No edema in upper and lower extremities.
• Respiratory: Clear breath sounds bilaterally with no wheezing, rales, or rhonchi.
• Abdomen: Soft and non-tender with no hepatosplenomegaly or masses palpated.
• Neurological: Alert and oriented to person, place, and time. Cranial nerves II-XII grossly intact. No motor or sensory deficits appreciated.

A/P
Assessment:

Palpitations – likely secondary to atrial fibrillation.
Fatigue, dyspnea with exertion, and sedentary behavior – likely related to myelofibrosis.
Diffuse eczema – planned to start Dupixant therapy.
Weight loss – needs further evaluation.
Petechial changes in the skin – likely due to thrombocytopenia from myelofibrosis.
Plan:

Admit the patient to the hospital for further management of atrial fibrillation, myelofibrosis, and weight loss.
Obtain an EKG to confirm atrial fibrillation and initiate rate control with diltiazem.
Consult with hematology/oncology for management of myelofibrosis and thrombocytopenia.
Start Dupixant therapy for eczema.
Obtain a nutrition consult for evaluation and management of weight loss.
Follow-up with the patient’s primary care provider for outpatient management and monitoring.

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References:
Blick C, Nguyen M, Jialal I. Thyrotoxicosis. [Updated 2022 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482216/
Nesheiwat Z, Goyal A, Jagtap M. Atrial Fibrillation. [Updated 2022 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526072/.
Robert R, Porot G, Vernay C, Buffet P, Fichot M, Guenancia C, Pommier T, Mouhat B, Cottin Y, Lorgis L. Incidence, Predictive Factors, and Prognostic Impact of Silent Atrial Fibrillation After Transcatheter Aortic Valve Implantation. Am J Cardiol. 2018 Aug 01;122(3):446-454.
Taylor K, Jones EB. Adult Dehydration. [Updated 2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555956/

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