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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
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
He was diagnosed with
type 2 diabetes twenty years ago and hypertension fifteen years ago.
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
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
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
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
Support the interventions outlined in your ‘P’ with scholarly
Please be sure to validate your opinions and ideas with
citations and references in APA format.
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