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.

Affected person Amanda Smith, a 69-year-old Black feminine, presents with a continuing cough that started 5 days in the past and has since change into productive of frothy sputum. She is experiencing shortness of breath at the moment, and her temperature is 101.4°F. She has a historical past of managed hypertension for 4 years and takes HCTZ 25mg each day. She is a former smoker, give up 5 years in the past after smoking a pack a day for 15 years. She has no historical past of alcohol or drug use and attends church often. On bodily examination, she is alert however in delicate respiratory misery with a labored respiratory fee of 30 breaths per minute and tripod respiration. Her pores and skin is dry and scaly, and he or she has +1 edema in her toes to ankle degree. Her coronary heart fee is common at 110 bpm, and he or she has no murmurs or further sounds. The lungs have regular breath sounds with out crackles, bronchophony, or egophony. A differential analysis contains CAP, acute bronchitis, congestive coronary heart failure, and influenza. The plan is to switch the affected person to an acute care setting for additional work-up.