Posted: July 16th, 2023

A 77-year-old white male comes into your office complaining of feeling dizzy

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.

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.

a few seconds ago

Helpful Assistant
S: The patient is a 77-year-old white male who presents with dizziness, shortness of breath, fatigue, and palpitations. He reports experiencing these symptoms intermittently over the past year, but they have persisted for the past three days. He has a history of type 2 diabetes and hypertension and is currently taking Lisinopril 20 mg daily and Metformin 1000 mg daily. His BP is 172/100, P 123 irregularly irregular, and R 20. His skin is warm, pale with a slight gray cast, are clear to auscultation, and his heart has an irregular rhythm.
O: The patient’s symptoms and physical exam findings suggest a possible cardiac arrhythmia. The patient’s hypertension is not well-controlled, and his heart rate is elevated. The patient’s medications may need to be adjusted to better control his blood pressure and manage his arrhythmia. Further diagnostic testing, such as an electrocardiogram (ECG) and echocardiogram, may be necessary to evaluate the patient’s cardiac function and rule out any underlying structural abnormalities.
A:
Therapeutics: The patient’s medications may need to be adjusted to better control his blood pressure and manage his arrhythmia. A beta-blocker, such as metoprolol, may be added to the patient’s regimen to help control his heart rate and rhythm. The patient should also be advised to monitor his blood pressure at home and report any readings above 140/90 to his healthcare provider. Non-pharmacologic interventions, such as reducing salt intake and increasing physical activity, may also be recommended to help manage the patient’s hypertension.
Educational: The patient should be educated on the importance of monitoring his blood pressure at home and reporting any readings above 140/90 to his healthcare provider. The patient should also be advised to seek medical attention immediately if he experiences any chest pain, shortness of breath, or fainting. The patient should be counseled on the importance of adhering to his medication regimen and making lifestyle modifications to help manage his hypertension and arrhythmia.
Consultation/Collaboration: Referral to a cardiologist may be necessary for further evaluation and management of the patient’s arrhythmia. The patient may also benefit from consultation with a registered dietitian to help develop a dietary plan to manage his hypertension.
References:
American Heart Association. (2021). Understanding Blood Pressure Readings. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
Mayo Clinic. (2021). Heart Arrhythmia. https://www.mayoclinic.org/diseases-conditions/heart-arrhythmia/symptoms-causes/syc-20350668
National Heart, Lung, and Blood Institute. (2021). How Is High Blood Pressure Diagnosed? https://www.nhlbi.nih.gov/health-topics/high-blood-pressure/diagnosis