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.

Amanda Smith is a Black woman aged 69 who presents with a persistent cough. It began five days ago, and it has now become a source of thickened sputum. She is experiencing shortness of breath today, and her temperature is 101.4°F. Her history includes controlled hypertension over 4 years. She takes 25mg of HCTZ daily. After 15 years of smoking, she quit the habit 5 years ago. Her past history is free from alcohol and drug abuse. She attends church every Sunday. On physical examination, she was alert and in mild respiratory distress. She has a labored breathing rate of 30 beats per minute with tripod breathing. She is dry and flaky, with +1 edema from her toes. Her heart rate is normal at 110 beats per minute, with no additional sounds or murmurs. Normal sounds are heard in the lungs, including no crackles, bronchophony or egophony. A differential diagnosis could include CAP, acute Bronchitis, congestive Heart Failure, or influenza. For further treatment, the plan is for the patient to be transferred to an urgent care facility.

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