Nursing Homework week 3 Clinical

68-year-old Hispanic male with a 3-year history of COPD presents for follow-up. Reports progressive shortness of breath over the last month, especially with exertion (walking short distances). Cough is productive with white sputum. Denies fever, hemoptysis, or chest pain. Admits to continued smoking (½ pack per day). Uses albuterol inhaler PRN but not consistently. States difficulty affording long-acting inhaler prescribed previously. No recent hospitalizations.

Past Medical History

· COPD (diagnosed 3 years ago)

· Hypertension

· Hyperlipidemia

Medications

· Albuterol inhaler PRN

· Lisinopril 10 mg daily

· Atorvastatin 20 mg daily

Allergies

· NKDA

Social History

· Current smoker (½ pack/day, 40 pack-year history)

· Denies alcohol or illicit drugs

· Retired construction worker

Review of Systems (ROS)

·

· Dyspnea on exertion, chronic cough with sputum

· Denies chest pain, fever, chills, hemoptysis, or edema

Physical Exam

· Vitals: BP 138/82, HR 88, RR 20, SpO₂ 93% on room air

· General: Appears mildly dyspneic with exertion

· Lungs: Decreased breath sounds bilaterally, scattered wheezes, prolonged expiratory phase

· Heart: Regular rate and rhythm, no murmurs

· Extremities: No edema, no cyanosis

Assessment

· COPD, moderate, with recent increase in dyspnea

· Hypertension, stable

· Hyperlipidemia, controlled

Plan

· Start tiotropium inhaler daily (long-acting anticholinergic)

· Continue albuterol inhaler PRN, educate on proper use

· Smoking cessation counseling provided; offered nicotine patch

· Order spirometry, CBC, CMP, chest X-ray

· Continue lisinopril and atorvastatin

· Follow-up in 6 weeks or sooner if symptoms worsen

Coding

ICD-10 Codes

· J44.9 – Chronic obstructive pulmonary disease, unspecified

· I10 – Essential hypertension

· E78.5 – Hyperlipidemia, unspecified

· Z72.0 – Tobacco use

CPT Codes

· 99214 – Office or other outpatient visit, established patient, moderate complexity

· 94010 – Spirometry, including graphic record

· 71046 – Chest X-ray, 2 views

· 80053 – Comprehensive metabolic panel (CMP)

Clinical Notes (Summary for Typhon): 68-year-old Hispanic male with COPD (diagnosed 3 years ago), HTN, and hyperlipidemia presented with increased dyspnea on exertion and chronic productive cough. Exam revealed decreased breath sounds, wheezing, SpO₂ 93%. Started tiotropium inhaler, continued albuterol PRN, and provided smoking cessation counseling. Spirometry, CMP, and chest X-ray ordered. Will follow up in 6 weeks.

,

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications: (including OTC and vitamins)

·

PMH:

Immunizations:

Preventive Care: Preventive Screenings: (for results already obtained before this encounter) – Pap smear: ______ – Mammogram: ______ – Colonoscopy: ______ – Lipid panel: ______ – A1C: ______ – STI screen: ______ – Depression screen (PHQ-9): ______

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATE

Chief Complaint (which must be stated between “__”)

Symptom analysis/HPI:

Clinical Tools Used (if applicable), otherwise state N/A – PHQ-9: ___ /27 – GAD-7: ___ /21 – AUDIT-C / DAST:

Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

OBJECTIVE DATA

VITAL SIGNS: LABS / DIAGNOSTICS REVIEWED (if available): – CBC: – Lipid Panel: – A1C: – EKG: – Imaging (if done):

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT

Red Flags / Reasons for Escalation: – [ ] None noted – [ ] Positive suicidal ideation – [ ] Unstable vital signs – [ ] Abnormal exam requiring urgent referral

Clinical Note

(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)

Example: “Pt came into our clinic today c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… On examination I noted erythema in the ear canal…, this, and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3) along with the rationale behind them. (why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)

–

–

–

PLAN

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones – tailored to this specific patient – not in general)

Follow-ups/Referrals

Visit Complexity / CPT Code: _______

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).