The family of a 62-year-old white female call your office and ask if you can see their family member. Question
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Asked by Kathybarbay
The family of a 62-year-old white female call your office and ask if you can see their family member. The person being requested to be seen is known to you for the last twenty years.
SOAP note (Subjective Objective Assessment). list as SOAP AND EXPLAIN USING JOURNAL CITATIONS INCLUDED AND LIST REFERENCES
She is your former supervisor and a fellow FNP.
The family reports your colleague is demonstrating signs of dementia.
They note that she 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.
Your friend 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.
You have seen a few of her patients in your practice over the last couple weeks because ‘she is never in her office or available’ over the last few weeks.
You reflect on your last few conversations with your colleague and think to yourself that you also thought she seemed ‘off her game’.
You recommend her family take her to Urgent Care and you convince your colleague this is in her best interest.
Labs drawn at Urgent Care reveal a Hgb of 8 and HCT of 24.
According to Wolters et al. (2019), to determine the long-term association of hemoglobin levels and anemia with risk of dementia and explore underlying substrates on brain MRI in the general population. Low and high levels of hemoglobin are associated with an increased risk of dementia, including AD, which may relate to differences in white matter integrity and cerebral perfusion.
PLAN:
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
Wolters, F. J., Zonneveld, H. I., Licher, S., Cremers, L., Heart Brain Connection Collaborative Research Group, Ikram, M. K., Koudstaal, P. J., Vernooij, M. W., & Ikram, M. A. (2019). Hemoglobin and anemia in relation to dementia risk and accompanying changes on brain MRI. Neurology, 93(9), e917-e926. https://doi.org/10.1212/WNL.0000000000008003
SCIENCE
HEALTH SCIENCE
NURSING
NURSING MS NU 636
The family of a 62-year-old white female call your office and ask if you can see their family member
