You are seeing a 62 year old white female for her annual visit. Presented below are some pertinent subjective and objective data that you elicited during your comprehensive assessment session with the patient (note – this is not the entire subjective and objective data set for this office visit).
PMH: HTN, Hyperlipidemia
Social History: divorced, employed full time as a graduate nursing program professor, no smoking history, reports on a rare occasion she may have a 2 – 3 ounces of wine when dining out [less than 6 times a year]
Health Maintenance Activities: 1 ½ to 2 hours of exercise every morning [45 – 60 minutes of yoga, 45 – 60 minutes of step aerobics]; low glycemic Pescatarian; has not engaged with recommended colonoscopy, does not have screening mammograms, does not get a flu shot and has not had any other recommended adult immunizations
Review of Systems
Cardiovascular: reports hypertension diagnosed at 27 years of age, controlled on 5mg Lisinopril daily; reports elevated total cholesterol level for the last decade or so with no pharmacologic treatment; denies chest pains, palpitations, lower extremity edema
Constitutional – Ht. 64 inches, Wt. 127 pounds [BMI 21.8], BP 112/60, P 68, T 97.9 temporal, R 16, SpO2 99%
Integument – pink, warm and dry to touch
Eyes – no arcus senilis
Cardiovascular – heart regular rate and rhythm, S1 and S2; no S3 or S4, murmur or gallop; no carotid bruits; radial pulses palpable and pedal pulses 2+; no lower extremity edema; capillary refill < 3 seconds bilateral
Lipid panel – Total cholesterol 302, HDL 117, Triglycerides 45
Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly literature. 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 in order 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.
Please be sure to validate your opinions and ideas with citations and references in APA format.
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