cough case study – 550 words

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. 

Location: XYZ Family PracticeYou 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 HistoryMarried – 2 adult children A & WNon-Smoker now. Smoke 1 pack a day for 15 years. Quit x5 years agoNo alcohol or drug useBaptist, attends church regularly and is a member of the choirFamily HistoryMother – Deceased at age 27 from traumatic accidentFather – Deceased age 78 related to renal failure secondary to diabetes type IISiblings – one brother age 61 A & WMedical/Surgical/Health Maintenance HxMeasles, mumps and chicken pox as a child.Tetanus/Diptheria/Pertussis – Last dose 2 years agoInfluenza – Last dose 9 months agoPneumococcal vaccine at age 65Zostivax at age 60Chronic diagnoses – HTN x 5 yearsTakes HCTZ 25 mg dailyROSGeneralUsual weight has been maintainedFever for 5 days up to 101SkinDry skin, uses emollient frequentlyHEENTWears reading glassesDentition fair. Partial upper dentureNeckNo swelling or stiffnessChestSubsternal pain on coughRespiratoryBegan 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.CVNo CP at rest or when not coughingPVSome swelling of feet and ankles at end of day, relieved by elevating feetGIDecreased appetite for one weekNo change in bowel habitsGUNo frequency, hesitancy, nocturia or change in bladder habitsGenitaliaNo changesMSStiffness in hands and legs on awakening. Relieved with activityPsychNo depression, anxiety, or memory changeNeurologicNo numbness, weakness, headache, change in mentation, or paralysisHematologicNo past anemiaEndocrineNo 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 lbsGeneral appearance – Alert in all spheres, in mild respiratory distress, able to answer questions with short sentences, tripod breathingHEENT –Eyes ,ear, nose, head wnlMouth -mucosa dryPharynx – tonsils present not enlarged, normal pink colorLymph – no enlargementSkin – Dry and scaly legs and arms. Tenting of skin notedHeart- regular rhythm at 110 bpm, no murmurs or extra soundsLungs – normal breath sound without crackles, bronchophony or egophonyAbdomen – no mass, tenderness, rigidityExtremities – Hands – no swelling, Feet/legs – +1 edema feet to ankle levelPedal pulses – wnlDifferential diagnoses:CAPAcute bronchitisCongestive heart failureInfluenzaPlan – transfer to acute care setting for further work-upAssignment Details: