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 â€˜skipping beatsâ€™.
- 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
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note (SubjectiveObjectiveAssessmentPlan).
Structure your â€˜Pâ€™ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the â€˜headingâ€™ and after the â€˜:â€™ input N/A]
Therapeutics:pharmacologic interventions, if any â€“ 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 â€˜therapeuticsâ€™ 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 â€˜Advanced Care Planningâ€™ with the patient/patientâ€™s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate â€“ 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 â€˜Pâ€™ with scholarly resources.