MN568 Purdue University Influenza Patient Medical Report Location: XYZ Family Practice
You are a Nurse Practionor 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.
CardioVasculer
No Chest Pain at rest or when not coughing
PeripheralVascular
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
GenitoUrinary
No frequency, hesitancy, nocturia or change in bladder habits
Genitalia
No changes
Muscle Strength
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.
Please review the grading rubric under Course Resources in the Grading Rubric section. Unit 3 Written Assignment: Elevator Consult Assignment
Content Rubric
Oral Presentation
Introductory
Emergent
0 – 1.9
2 – 2.9
Presentation was not concise
or orderly by systems and did
not included an HPI, pertinent
finding on exam or,
suggested plan of care.
Extraneous information was
included.
Presentation was not
concise, was not orderly by
systems and included an
incomplete HPI, incomplete
pertinent finding on exam
and an incomplete
suggested plan of care.
Extraneous information was
included.
APA format with
supporting evidence
Did not follow APA format
based resources less
than 3 years old.
Feedback:
Major errors with APA
formatting
Consult Assignment
Total available points =
Practiced
Proficient/Mastered
3 – 3.9
4
Presentation was concise,
but was not orderly by
systems and included an
incomplete HPI, incomplete
pertinent finding on exam
and an incomplete
suggested plan of care. No
extraneous information was
included.
Presentation was concise,
orderly by systems and included
HPI, pertinent finding on exam,
suggested plan of care. No
extraneous information was
included.
10
Score
Weight
Final Score
4
90%
3.60
Text, title page and references
page follow APA guidelines. No
grammar, word usage or
Text, title page, and references page follow APA guidelines . Minor references
and grammar
4
10% errors
punctuation errors. Overall style
is consistent with professional
work.
0.40
10
Final Score
Percentage
100%
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