Learning Goal: I’m working on a english multi-part question and need an explanation and answer to help me learn.
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 6’2”, 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
Support the interventions outlined in your ‘P’ with scholarly resources.
Please be sure to validate your opinions and ideas with citations and references within 5 years in APA format.