A 77-year-old white male comes into your office complaining of feeling dizzy, short of breath, easily fatigued and having a sensation of his heart ‘skipping beats’.
He reports he has had these same symptoms numerous times over the last year or so, but they only lasted for about a day.
He thought since he has been experiencing them now for about 3 days he should come in and get checked out.
He was diagnosed with type 2 diabetes twenty years ago and hypertension fifteen years ago.
Current medications include Lisinopril 20 mg daily and Metformin 1000 mg daily.
BP 172/100, P 123 irregularly irregular, R 20
Skin is warm, pale with a slight gray cast; lungs are clear to auscultation; heart irregular rhythm
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.
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
Support the interventions outlined in your ‘P’ with scholarly resources.
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