Description
I will upload an example for you.
Case Study #2
Date: November 12, 2016, 2:00 pm
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 wnl
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 – wnl
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. Three reference not older than 5
years old. No plagiarism .
