Leukemia Service Progress Note History of Present

Leukemia Service Progress Note History of Present : personally saw and examined this patient with the medical staff on morning rounds and discussed the impression and plan with them. The patient is a 58 yo woman with HTN, DM (un medicated)chronic migraines, who presented to the ED 9/29 with worsening right upper and lower extremity pain 5 / p mechanical fall 12 days prior to admissionIn ED had plain films of R Ankle and Tib/Fib along with the pelvis that were negative CTHead / C – Sg Spine were negative as wellDue an episode of epistaxis and noted bruising a CBC was performed and was notable for a WBC of 10.08, Hgb of 12.2 and platelets 10k with 70% blasts and promyelocytes noted Heme / O * nc was consulted and patient was admitted to the leukemia service for further work up and management of probable acute leukemia. Yesterday she complained of mild abd pain and later worsening headache 9/30 head CT: negative for acute pathology 9/30 CT ChestBL patchy /GGO infiltrates at the bases09/30 CT A / Pi Negative 09/30 PB Flow Cytometry Involvement by acute myeloid leukemia , immunophenotypically suggestive of APL09/30 PB FISH analysis using PML/RARA probe is POSITIVE for t 15:17 ) (PML RARA) in 89 cells. This finding is consistent with acute promyelocytic leukemia (APL)10/03 MRI Brain and orbits: MRI of the brain with and without contrast without a comparison study showing small scattered foci of diffusion abnormal signal intensity cortical based specially over the left frontal convexity and 1 or 2 foci in the right frontal region with no associated abnormal enhancement most consistent with probable small acute embolic cortical infarctsMild distension of the optic nerve sheaths Mild flattening of the posterior globes at the level of the optic discs bilaterally Prominence of CSF within a partially empty sellaFindings can be seen in the setting of intracranial hypertension 10/5 CT Angio: Neck CTA: No hemodynamically significant stenosis aneurysm or dissection Head CTA: No large vessel occlusion , aneurysm or dissection. She is currently doing well and has no new complaints this morning Last day of idarubicin today Can you please help me figure out what kind of medication and interventions and evaluations should be done for someone with these problems. Thank you Image transcription text Student Name: Date of Service: Patient Initials: Date of Submission: Steps to Design a Concept Map 1. The first step is to choose one of your assigned clients. 2. Once a client is chosen, collect information about the client’s health problems. U… Show more Problem 1) Bleending Problem 2) infection Problem 3) Rise for Fall Problem 4) Pain can you please help me complete the concept map with this history that I have here of a patient. my teacher does not want nursing diagnosis for the problems.

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