MN 561 Assignment XYZ Family Practice

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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

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



Usual weight has been maintained

Fever for 5 days up to 101


Dry skin, uses emollient frequently


Wears reading glasses

Dentition fair. Partial upper denture


No swelling or stiffness


Substernal pain on cough


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.


No CP at rest or when not coughing


Some swelling of feet and ankles at end of day, relieved by
elevating feet


Decreased appetite for one week

No change in bowel habits


No frequency, hesitancy, nocturia or change in bladder


No changes


Stiffness in hands and legs on awakening. Relieved with


No depression, anxiety, or memory change


No numbness, weakness, headache, change in mentation, or

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No past anemia


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


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:


Acute bronchitis

Congestive heart failure


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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