Mrs. B is a 62-year-old white female who presents to your office with her daughter for follow-up after a recent Urgent Care visit

Mrs. B is a 62-year-old white female who presents to your office with her daughter for follow-up after a recent Urgent Care visit.

 

· The daughter reports Mrs. B is demonstrating signs of dementia.

 

· Her daughter notes that the patient has not been eating much for the past few weeks reporting she has a gnawing pain in her stomach.  If she does eat, she reports getting ‘full’ very quickly.  She reports feeling mildly nauseous for the last few weeks.

 

· The patient sustained a fall injury about 9 months ago from a ladder.  She shattered some teeth and developed an infection.  She is under the care of an oral surgeon.

 

· The patient’s coworkers have mentioned to the daughter that ‘she is never in her office or available’ over the last few weeks and seems ‘off her game’.

 

· She was evaluated yesterday at Urgent Care and instructed to follow-up in your office today.

 

· Labs drawn at Urgent Care reveal a Hgb of 8 and HCT of 24.

 

Please develop a discussion that responds to each of the following prompts.  Where appropriate your discussion needs to be supported by scholarly resources.  Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.

 

Initial Post

 

Utilize the information provided in the scenario to create your discussion post. 

 

Construct your response as an abbreviated SOAP note ( Subjective  Objective  Assessment  Plan).

 

Structure your ‘P’ in the following format: [NOTE:  if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]

 

Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]

 

Educational: health information clients need to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit

 

Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making