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Asked by bsj307

You have a 57 year old mixed race male (black and Asian) who comes into your office for a screening to participate in a study to evaluate the effectiveness of a home cervical traction device on neck pain and intervertebral disc space. He has a history of neck pain and was diagnosed six years ago with spinal stenosis at the C5-C6 level.

During the screening the gentleman is found to have a BP of 217/109. When you question him about this BP measurement he reports to you that he knows that his blood pressure has been in that range for about the last decade. He reports he has not seen a health care professional about his elevated blood pressure and does not have a health care professional that he sees on a routine basis. He is a healthcare professional at the provider level.

Based on the blood pressure measurement he does not meet the inclusion criterion for the cervical traction device research study.

Utilize the information provided in the scenario to create a discussion post. 
Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
Structure your ‘P’ in the following format: if any of the 3 categories is not applicable to your plan please put N/A

Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for over the counter 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

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