Reference no: EM133468530
Mr. Jones is a 73-year-old man, who lived independently with his wife of 55 years. He has hypertension, hyperlipidemia, and Type 2 diabetes. He takes 2 types of blood pressure medications, Lipitor for blood lipid, and glipizide and Glucophage for diabetes as well as a senior multivitamin, vitamin D, and 800 mg of Ibuprofen and smokes marijuana each day for pain. In the past 6 months, his wife, who did most of the cooking and taking care of the traditional housewife activities, passed away suddenly. He lost 45 lbs. in the past 6-months, he is 5 ft 11 inches tall, usual body weight was 195 lbs. The most recent lab values are albumin was 3.3 g/dL, hemoglobin was 12 mg/dL, hematocrit was 39%, HgbA1c was 8.5%, fasting blood glucose 160 mg/dL, cholesterol 190 mg/dL, triglycerides were 220 mg/dL, his triceps skinfold is 4 mm and upper arm muscle area is 26 cm2 His energy intake is 1500 Kcal per day with protein intake of 60 grams/day. He does not have appetite and complains that the food no longer tastes as good as he remembered.
What are your assessment and findings for Mr. Jones, don't forget ABCD
Complete a SOAP notes for Mr. Jones with 2 PES statements.
What are your interventions and recommendations?
How would you monitor his progress and evaluate his outcome?