Title:
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

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