QUESTION
Discussion Prompt
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.
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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.
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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.
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.
ANSWER
Abbreviated SOAP Note: Evaluation and Management of Cardiac Symptoms in a 77-Year-Old Male with Comorbidities
Subjective
The patient is a 77-year-old white male presenting with symptoms of dizziness, shortness of breath, fatigue, and palpitations. He reports experiencing similar symptoms intermittently over the past year, but they usually resolve within a day. Concerned that these symptoms have persisted for three days, he decided to seek medical evaluation. The patient has a medical history of type 2 diabetes for 20 years and hypertension for 15 years. His current medications include Lisinopril 20 mg daily and Metformin 1000 mg daily.
Objective
Upon examination, the patient’s blood pressure is elevated at 172/100 mmHg, and his heart rate is irregularly irregular with a rate of 123 beats per minute (Salles et al., 2016). His respiratory rate is 20 breaths per minute. Physical examination reveals warm, pale skin with a slight gray cast. Lung auscultation is clear, but the heart exhibits an irregular rhythm.
Assessment
Based on the patient’s symptoms, medical history, and physical examination findings, several considerations come to mind. The patient’s palpitations, irregular heart rate, and dizziness raise concerns about a cardiac arrhythmia. Hypertension, in combination with these symptoms, may further contribute to the cardiovascular instability. Given the patient’s longstanding diabetes, other potential causes such as autonomic dysfunction or electrolyte imbalances should also be considered.
Plan
Therapeutics:
Immediate referral to a cardiologist for further evaluation of the patient’s cardiac arrhythmia and initiation of appropriate treatment.
Adjustment of antihypertensive therapy to achieve better blood pressure control. Considering the patient’s inadequate blood pressure control with Lisinopril alone, addition of a second antihypertensive agent may be necessary (Kochi et al., 2020). Potential options include a diuretic, calcium channel blocker, or beta-blocker, depending on individual patient factors.
Evaluation of the patient’s electrolyte levels, particularly potassium and magnesium, as imbalances can contribute to cardiac arrhythmias.
Consideration of a comprehensive medication review to identify any potential drug-drug interactions or adverse effects that may exacerbate the patient’s symptoms.
Educational
Patient education on the importance of strict blood pressure control and adherence to antihypertensive medications to reduce the risk of cardiovascular complications.
Explanation of the need for further cardiac evaluation and potential treatment options for the identified arrhythmia (Long et al., 2020).
Discussion on lifestyle modifications such as regular physical activity, weight management, and dietary modifications (e.g., DASH diet) to manage hypertension and diabetes.
Reinforcement of the importance of regular follow-up visits to monitor treatment effectiveness, adjust medications as needed, and address any concerns or new symptoms.
Consultation/Collaboration:
Collaboration with a cardiologist to manage the patient’s cardiac arrhythmia and determine the need for additional diagnostic tests, such as an electrocardiogram (ECG) or echocardiogram.
Consultation with a pharmacist to review the patient’s medication regimen for potential drug interactions, assess the appropriateness of the current therapy, and suggest alternatives if necessary.
Consideration of a referral to an endocrinologist to optimize diabetes management and assess for any potential autonomic dysfunction related to diabetes.
In summary, the patient’s symptoms, along with his medical history and physical examination findings, warrant immediate referral to a cardiologist for evaluation of a cardiac arrhythmia. Simultaneously, blood pressure control should be optimized, and consideration should be given to evaluating electrolyte levels and potential drug-drug interactions. Patient education should focus on the importance of adherence to medications, lifestyle modifications, and the need for regular follow-up visits to manage hypertension, diabetes, and the identified arrhythmia.
References
Kochi, A. N., Tagliari, A. P., Forleo, G. B., Fassini, G., & Tondo, C. (2020). Cardiac and arrhythmic complications in patients with COVID‐19. Journal of Cardiovascular Electrophysiology, 31(5), 1003–1008. https://doi.org/10.1111/jce.14479
Long, B., Brady, W. J., Koyfman, A., & Gottlieb, M. (2020). Cardiovascular complications in COVID-19. American Journal of Emergency Medicine, 38(7), 1504–1507. https://doi.org/10.1016/j.ajem.2020.04.048
Salles, G. F., Reboldi, G., Fagard, R., Cardoso, C. a. L., Pierdomenico, S. D., Verdecchia, P., Eguchi, K., Kario, K., Kario, K., Polónia, J., De La Sierra, A., Hermida, R. C., Dolan, E., O’Brien, E., & Roush, G. C. (2016). Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients. Hypertension, 67(4), 693–700. https://doi.org/10.1161/hypertensionaha.115.06981