Scenario
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.
Initial Post
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.
- What role does Anti-coagulant Therapy play among groups such as the patient in the study?
- Summarize a scholarly article that pertains to the case study and provide feedback.
