Hematology and Oncology

Medical Record 4:

Patient Information

• Name: [Patient's Name]
• Date of Birth: [Patient's DOB]
• Sex: Female
• Medical Record Number: [MRN]

-Date of Service: 03/15/2024

Medical Specialty: Hematology/Oncology

SOAP Note

Subjective

The patient, a 72-year-old gentleman, presents with chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. He was diagnosed with CLL in May 2018, with concurrent autoimmune hemolytic anemia, for which he has been on chronic steroids, currently taking prednisone 5 mg every other day. He reports an ulcer on his tongue and lip. He has discontinued prophylactic antivirals and antibacterial medications.

Current Medications

• Prilosec 20 mg b.i.d.
• Levothyroxine 50 mcg q.d.
• Lopressor 75 mg q.d.
• Vitamin C 500 mg q.d.
• Multivitamin q.d.
• Simvastatin 20 mg q.d.
• Prednisone 5 mg q.o.d.

Allergies

Vicodin

Objective

• Vitals: BP 120/74, HR 72, Temp 97.8°F, Weight 112.7 kg
• Physical Exam: Cold sore on the bottom lip, ulcer on the tongue, no cervical or supraclavicular adenopathy, clear lungs, regular heart rate with normal S1 and S2, soft abdomen, no hepatosplenomegaly, no lower extremity edema
• Laboratory Data: WBC 4.6, Hemoglobin 14.2, Hematocrit 42, Platelets 207,000

Assessment/Plan

• CLL with autoimmune hemolytic anemia: Continue prednisone 5 mg every other day. Consider reducing to 1 mg daily and start Valtrex.
• Oral ulcer: Monitor, continue supportive care.
• Follow-up: Schedule a follow-up visit in one week.

This note is a representation for educational purposes and should not be used as a medical record. Always consult a qualified healthcare professional for accurate diagnosis and treatment.

Electronically signed by Jane Smith, NP. Date: 03/15/2024. Time: 10:45.