MN 561 Assignment XYZ Family Practice
MN 561 Assignment XYZ Family Practice
Location: XYZ Family Practice
You are an NP student in this practice. Your next patient is
the following:
I had to come in today because I have been coughing for a
long time
Amanda Smith (69 year old, black female) is a retired postal
worker. During the visit, she is coughing continually. She states the cough
started 5 days ago intermittently but 2 days ago it became constant. Her chart
indicates that she has been a patient of the practice for 5 years, gets care
regularly and her HTN has been controlled for 4 years.
Social History
Married 2 adult children A & W
Non-Smoker now. Smoke 1 pack a day for 15 years. Quit x5
years ago
No alcohol or drug use
Baptist, attends church regularly and is a member of the
choir
Family History
Mother Deceased at age 27 from traumatic accident
Father Deceased age 78 related to renal failure secondary
to diabetes type II
Siblings one brother age 61 A & W
Medical/Surgical/Health Maintenance Hx
Measles, mumps and chicken pox as a child.
Tetanus/Diptheria/Pertussis Last dose 2 years ago
Influenza Last dose 9 months ago
Pneumococcal vaccine at age 65
Zostivax at age 60
Chronic diagnoses HTN x 5 years
Takes HCTZ 25 mg daily
ROS
General
Usual weight has been maintained
Fever for 5 days up to 101
Skin
Dry skin, uses emollient frequently
HEENT
Wears reading glasses
Dentition fair. Partial upper denture
Neck
No swelling or stiffness
Chest
Substernal pain on cough
Respiratory
Began coughing 4 days ago. Started mild, intermittent and
non-productive. Two days ago became constant and productive of frothy sputum.
Keeps her awake at night. No relief with OTC cough syrup. She states she is
short of breath today.
CV
No CP at rest or when not coughing
PV
Some swelling of feet and ankles at end of day, relieved by
elevating feet
GI
Decreased appetite for one week
No change in bowel habits
GU
No frequency, hesitancy, nocturia or change in bladder
habits
Genitalia
No changes
MS
Stiffness in hands and legs on awakening. Relieved with
activity
Psych
No depression, anxiety, or memory change
Neurologic
No numbness, weakness, headache, change in mentation, or
paralysis
Hematologic
No past anemia
Endocrine
No change in weight, thirst, heat/cold intolerance.
Your physical exam reveals:
Temp 101.4, Resp 30 labored, no retractions, BP 135/92, HR
110, Pulse Ox 90 Wt 130 lbs
General appearance Alert in all spheres, in mild
respiratory distress, able to answer questions with short sentences, tripod
breathing
HEENT
Eyes ,ear, nose, head wall
Mouth -mucosa dry
Pharynx tonsils present not enlarged, normal pink color
Lymph no enlargement
Skin Dry and scaly legs and arms. Tenting of skin noted
Heart- regular rhythm at 110 bpm, no murmurs or extra sounds
Lungs normal breath sound without crackles, bronchophony
or egophony
Abdomen no mass, tenderness, rigidity
Extremities Hands no swelling, Feet/legs +1 edema feet
to ankle level
Pedal pulses wall
Differential diagnoses:
CAP
Acute bronchitis
Congestive heart failure
Influenza
Plan transfer to acute care setting for further work-up
Assignment Details:
The Elevator Consult
In this activity, you will practice giving a synopsis of
your patient to your preceptor. In practice, you may often give this type of
report if you are sending a patient for a consultation and your phone the
specialist to discuss the patient. This report should be concise and clear. The
receiver should, within one minute (slightly less for simple cases, slightly
more for complex cases) have a picture of the patient in his/her head. You will
report on ONLY items pertaining to the acute problem in this case. Do not
include extraneous material or material not directly impacting the
decision-making regarding this problem. Remember, this is a FOCUSED visit and
assessment to evaluate a focused concern. The history and physical exam applies
techniques relevant to the specific complaint for the patient at that visit.
Your report should be similarly focused, providing only information that
relates specifically to the presenting problem.
Please review the grading rubric under Course Resources in
the Grading Rubric section.
How to Submit:
Submit your Assignment to the unit Dropbox before midnight
on the last day of the unit.
When you are ready to submit your Assignment, select the
unit Dropbox then attach your file. Make sure to save a copy of the Assignment
you submit.
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