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.

Patient Amanda Smith, a 69-year-old Black female, presents with a constant cough that began 5 days ago and has since become productive of frothy sputum. She is experiencing shortness of breath today, and her temperature is 101.4°F. She has a history of controlled hypertension for 4 years and takes HCTZ 25mg daily. She is a former smoker, quit 5 years ago after smoking a pack a day for 15 years. She has no history of alcohol or drug use and attends church regularly. On physical exam, she is alert but in mild respiratory distress with a labored respiratory rate of 30 breaths per minute and tripod breathing. Her skin is dry and scaly, and she has +1 edema in her feet to ankle level. Her heart rate is regular at 110 bpm, and she has no murmurs or extra sounds. The lungs have normal breath sounds without crackles, bronchophony, or egophony. A differential diagnosis includes CAP, acute bronchitis, congestive heart failure, and influenza. The plan is to transfer the patient to an acute care setting for further work-up.