Soap note systemic lupus erythematosus rubric attached no plagiarism.
S: A 32-year old female presents six months of intermittent fevers, night sweats and fatigue. She also reported abdominal pain, and a weight loss of 10 pounds over the last two months. She claims to have recently been in Central America. However, she denies having any medical histories.
O Vital signs within normal ranges. The physical examination is notable because of diffuse abdominal tenderness, without rebounding or guarding. Laboratory tests reveal elevated liver enzymes, anemia and thrombocytopenia. A CT scan of abdomen reveals hepatosplenomegaly, as well as multiple hypodense liver and spleen lesions. A biopsy of the liver reveals granulomatous, acid-fast bacilli. The chest X-ray shows no abnormalities.
A: This patient was diagnosed with Mycobacterium tuberculosis disseminated (TB).
- Metastatic cancer
P: A four-drug regimen against TB was prescribed (isoniazid pyrazinamide ethambutol pyrazinamide) to the patient. The specialist in infectious diseases will be contacted for any further treatment.
- Centers for Disease Control and Prevention. (2021). Tuberculosis. https://www.cdc.gov/tb/topic/basics/default.htm
- World Health Organization. (2021). Global tuberculosis Report 2021 https://www.who.int/publications/i/item/9789240037021
- Leung, A. N. (2015). The basics of pulmonary tuberculosis. Radiology, 277(1), 305-322. https://doi.org/10.1148/radiol.2015141529