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Posted: November 17th, 2025
A 60-year-old white female presents to your office for a follow-up
A 60-year-old white female presents to your office for a follow-up after a recent Urgent Care visit with her daughter. The patient’s daughter reports that the patient has not been eating much for the past few weeks and complains of a gnawing pain in her stomach when she does eat and reports that she seems to be getting “full” very quickly with eating. The patient complains of mild nausea over the last two weeks. The patient has a history of a recent fall from a ladder about 9 months ago in which she shattered multiple teeth and develop and infection. She has been under the care of an oral surgeon for this. Her daughter reports that she has been having an increase in forgetfulness and that the patient’s colleagues have noticed she seems to be “off her game” for the last few weeks. Yesterday she was evaluated at Urgent Care and found to have a hemoglobin of 8.5 and hematocrit of 25, and she was instructed to follow-up in your office today. Upon examination today his lung sounds are clear and heart rhythm is regular. She has mild tenderness on palpation over her upper abdomen, but normal bowel sounds. Her skin is pale and dry. No other abnormalities are noticed on exam. 1) Provide your diagnosis. 2) Discuss how you would treat the patient’s current presentation and provide a rationale supported by scholarly reference for your treatment plan. 3) Include your specific prescription(s) for the patient. (This must include the medication name, dose, route, and frequency as well as any special instructions that apply) 4) Describe the patient education you would provide in relation to your treatment plan. 5) Provide your plan for follow-up and/or referral (if indicated)
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