MN568 Purdue University Influenza Patient Medical Report Location: XYZ Family Practice You are a Nurse Practionor student in this practice. Your next pati

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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