Nursing home resident: Sara Ault 78 y/o African-American female with CHF, HTN (hypertension), DM type II (diabetes mellitus)
Progess Note: Subjective: c/o memory decline, tremors, difficulty sleeping, and fatigue. Objective: tremors in hands, MMSE score 24/30; previous score 29/30 (mini mental status exam for evaluation of Alzheimer's or other dementia; 30/30 is normal) Medications: Altace (CHF), Gluocophage (DM); Lasix (CHF), Slow K (potassium supplement to replace potassium loss when on diuretic). Lab: B-12 levels-low; Antibodies Test: +antibodies against intrinsic factor;Schilling Test: intrinsic factor (-) Assessment: symptoms likely due to lack of B-12 absorption; autoimmune disorder with absence of intrinsic factor and medications glucophage and Slow K decreasing absorption of B-12 from intestines Dx: Pernicious anemia Plan: Discuss with resident and daughter; B-12 injections weekly; change glucophage, reduce Slow K and monitor potassium levels. The nursing home physician discusses the medication changes and explains pernicious anemia in layperson's terms.
