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, a Black female aged 69, presented with a chronic cough. The cough started 5 days ago. Since then, she has been producing frothy stool. She is experiencing shortness of breath today, and her temperature is 101.4°F. For the past 4 years, she has been under controlled hypertension and is currently taking HCTZ 25mg every day. Former smoker who quit smoking five years ago, after having smoked a pack per day for fifteen years. Her past history is free from alcohol and drug abuse. She attends church every Sunday. She is awake but alert, and has a moderate respiratory problem. Her rate of breathing is 30 breaths per hour. She has dry, scaly skin and 1 edema at her ankles. She has normal heart beat at 110 bpm and no extra sounds or murmurs. Her lungs produce normal sounds, without crackles or bronchophony. It is possible to diagnose CAP, acute Bronchitis, congestive Heart Failure, or influenza as a differential. It is planned to move the patient into an acute care setting to continue work-up.

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