Discussion #1:
Instructions:
Discussion post for this week, please take the following descriptive information and place it with the appropriate categories listed.
- Based on the descriptive information, would this be a focused or comprehensive assessment and, if focused, what system or systems would you want to assess and why?
Descriptions
- Presents with c/o headache
- Pain is a ‘4’ on a scale of 1-10
- Scoliosis corrected with Charleston brace, broken toe
- No cold/sinus symptoms
- Eye exam 2 years ago
- No medications, NKDA
- No hospitalizations
- No tobacco use, wine once monthly, no recreational drug use
- Single, lives alone
- Traveled to UK, Caribbean in past 3 months
- Throbbing for past 2 hours, can feel pulse in temple
- Sports-induced asthma
- No fever, no changes in vision
Categories
- Chief Complaint
- History of Present Illness
- Past Medical History
- Personal and Social History
- Review of Symptoms
Discussion #2:
Scenario
You are seeing a 64-year-old Hispanic male for his diabetes management. He reports that his morning capillary blood sugar readings are ranging in the 150 to 190 range.
- Last month his Hgb A1C was 7.4
- He is on Metformin 1000mg twice a day and Glipizide 5mg daily.
- He walks a couple miles three to five times a week.
- A dietary review reveals that his daily total carbohydrate intake is in the range of 75 to 100 grams.
- Last eye exam did not reveal any problems. He wears reading glasses when needed.
- He does report some intermittent burning sensation in his feet.
- Ht 6’2â€, Wt 200 lbs, BP 118/72, P 72, R 17
- Heart regular rhythm, without murmur or gallop
- Lungs clear
- Monifilament testing does not reveal any decreased sensation in the feet
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 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
Discussion #3:
Scenario
You are evaluating a 53-year-old white female who wants to talk to you about lab work that she had done recently at “Any Lab Test Nowâ€.
- She wanted to have lab work done because she was feeling tired and unmotivated. Additionally, she had put on about 15 pounds even though she has been teaching yoga 2-3 times a week for the last few years.
- The lab results reveal a TSH of 93.
- She reports her last menstrual period was about 3 years ago. She experienced some menopausal symptoms of hot flashes and night sweats. However, she states they weren’t too much of a problem and those resolved a couple years ago.
- She denies any difficulty swallowing or neck pain/tenderness.
- Constitutional exam: 5’5†tall, 154 pounds, BP 145/88, P 60, R 16, Temp 97.2
- Neck – nontender, mild goiter with right side of thyroid larger than the left side
- Heart – regular rhythm without murmur or gallop
- Lungs – clear
- Skin – dry on extremities with some flaking noted
- A slowness of the relaxation phase of the Achilles tendon reflex is noted
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 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
