Scenario: You are seeing an 89-year-old male who has a history of smoking 2 packs of cigarettes a day for 69 years.
He quit smoking cold turkey when he was 78 years old.
He is in your office for a general health evaluation. He reports ongoing challenges with ‘belching’ but other than that he conveys that he is feeling pretty good.
He is on no routine medications.
During your interview with the patient you note that he utilizes pursed lip breathing. At times you note a faint ‘whistling’ sound associated with his respiratory effort.
In conducting your review of systems he reports a cough, particularly in the mornings, productive for thick clear to white sputum.
When queried about shortness of breath he does indicate that he gets SOB more easily than he used to.
His breath sounds are course and diminished in the lower lobes bilaterally.
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)
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.
The post and responses are valued at 40 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.