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Katie 65 year old female

CC: Cough that started one week ago and is worse at night and decrease in energy that is
keeping her from doing her normal activities
O: one week ago
L: chest
D: constant
C: non-productive, gets easily winded
A: Laying down or walking
R: not discussed
T: not discussed
PMH: HTN and hyperlipidemia
Current medications: Evista, HCTZ, multivitamin daily
Allergies: NKDA
Prior illnesses/injuries: chicken pox, measles and rubella as a child. Denies past injuries.
Operations and hospitalizations: Tonsillectomy and cholecystectomy. Hospitalized for
childbirth and surgeries.
Immunizations: not discussed
Family Hx: One daughter is mentioned, but nothing is discussed about her health. Nothing was
mentioned about her parents or siblings.
Social Hx: Denies alcohol or tobacco use.
Constitutional: decrease in energy.
Respiratory: Non-productive cough, gets easily winded.
Allergies: seasonal allergies to pollen, reports hayfever.
Physical Exam
VS: Ht: 62 in, Wt 140lbs T 100.4 BP 130/90 P 80 R 22,even, Sats 96%
Constitutional: Cooperative, talkative, appropriate
Skin: Pale pink, no cyanosis or palloe.
HEENT: Normocephalic, hair thick and distributed throughout entire scalp. Conjunctiva clear,
non-icteric, PERRLA, EOMs intact. Tympanic membranes gray and intact with light reflex
noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist, no lesions
or exudate. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy
or tenderness noted. Thyroid midline, small, firm.
CV: Heart RRR without murmur.
Respiratory: Lung sounds clear on left side. On the right side, crackles noted on inspiration that
did not clear with coughing. Slight lag was noted on the right side on assessment of expansion.
Tactile fremitus symmetrical. An asymmetrical dullness was noted over right side of back.
GI: Abdomen soft, non-tender bowel sounds auscultated in all four quadrants fields. No
organomegaly noted.
Chest x-ray shows a dense shadow in the RLL.

1. Community Acquired Pneumonia (ICD 9 code 486)
Schub & Cabrera (2015) state that the signs and symptoms of community associated pneumonia
include fever, tachycardia, tachypnea, chills, dyspnea, and cough with or without sputum. If the
pleura is involved, sharp chest pains with respiratory movements can occur. Other manifestations
include headache, excessive sweating, fatigue, myalgia, abdominal pain, and in older adults,
confusion Albert (2010) states that cough may be the only initial presenting symptom of
pneumonia in older adults. With Katie having a cough that has been getting worse, her
temperature, her decrease in energy and her chest x-ray showing a dense shadow in the RLL, this
is what lead me to my primary diagnosis of pneumonia.


1. Medications: Azithromycin 250mg Sig: Take 500mg PO on day 1, 250mg on days 2-5.
NO refills. File (2015) states that "for uncomplicated pneumonia in patients who do not
require hospitalization, have no significant comorbidities and/or use of antibiotics within
the last three months, and where there is not a high prevalence of macrolide-resistant S.
pneumoniae strains, we recommend any one of the following oral regimens-
azithromycin 500mg on day one followed by four days of 250 mg a day or 500 mg daily
for three days, clarithromycin 500mg twice daily for five days, clarithromycin XL two
500mg tablets daily for five days, or doxycycline 100mg twice daily. I chose to
prescribe azithromycin because it is cheap, easy to take, and it does not interact with the
medications she already takes daily.
2. No additional tests are needed at this time. If her cough became productive, I could get a
sputum sample to confirm what type of pneumonia she has.
3. Pt should be educated on needing to increase her fluids to help prevent dehydration. She
will need to get plenty of rest. She can use Tylenol or motrin to control her fever. She
should practice good hand hygiene. She will need to call if her symptoms get worse,
develops SOB, or if she feels like something is not right. She will need to finish all of her
antibiotics even if she is feeling better before they are gone.
4. No referral is needed at this time.
5. I would want to see Katie back in 1 week to see how she is doing.

Albert, R. (2010). Diagnosis and treatment of acute bronchitis. American Family Physician,
82(11), 1345-1350.

File, T.M. (2015). Treatment of Community-acquired pneumonia in adults in the outpatient

setting. In J.B. Post (Ed.), UpToDate. Retrieved from

Schub, T., & Cabrera, G. (2015). Pneumonia, Community-Associated.

Patrick 40 year old male
CC: itchy, dry, flaky skin on elbows
O: not discussed
L: bilateral elbows
D: constant
C: itchy, dry, flaky that bleeds when the skin is pulled off
A: stress
R: not discussed
T: Used his wifes hand lotion with no relief.
PMH: Had a similar rash years ago that went away on its own, no other medical history.
Current medications: No prescription medication.
Allergies: NKDA
Prior illnesses/injuries: Not discussed
Operations and hospitalizations: Hospitalization at age 8 for broken leg that required traction.
Immunizations: Up to date.
Family Hx: Mother and father are both deceased. Mother died at 51 from a brain tumor and
father died at 53 from leukemia. He has one brother who is in good health.
Social Hx: Works a plummer. Sleeps 5-6 hours a night. Denies etoh, tobacco or illicit drug use.
Constitutional: Feeling tired
Skin: itchy, dry, flaky skin that bleeds when the skin is pulled off.
Psychiatric: Pt reports feeling stressed and tired.
No other systems were discussed.
Physical Exam
VS: Ht 59 Wt 195lbs T98.4 BP 130/78, P 76 R 20 Sao2 98%.
Skin: Well-circumscribed deep red, scaling oval plaques noted to bilateral elbows. Right is worse
than the left. Scale is silvery white. No lesions noted on rest of body.
CV: RRR without murmur.
Respiratory: Lung sounds are clear bilaterally.

1. Psoriasis (ICD 9 696.1)
Feldman (2015) states that "psoriasis is a common chronic skin disorder typically characterized
by erythematous papules and plaques with a silver scale." These are sometimes itchy or sore and
can crack. Recognized triggers include skin trauma, throat infections and various medications,
and many patients report stress as an aggravating factor (Elwell & Craven, 2015).
1. Medications: Betamethasone 0.05% Cream Sig: apply to both elbows daily for 2 weeks.
NO refills (Feldman, 2015). If his psoriasis was not on an extensor surface, he could try
using hydration and emollients only. I will still recommend he use an emollient such as
petroleum jelly once his skin returns back to its normal thickness and the plaque has
2. No additional diagnostic tests are needed.
3. Pt should be educated on using the betamethasone cream as prescribed and then using a
daily emollient such as petroleum jelly. Stress can lead to psoriasis flair ups and I would
discuss different techniques to help decrease stress.
4. If his psoriasis does not start to clear up within 1 week, I would refer him to a
5. Patrick should return to see me in 1 week.
Elwell, R., & Craven, N. (2015). A glossary of terms to assist the recognition and diagnosis of
skin conditions associated with lower-limb chronic oedema. British Journal of Community
Nursing, S14-20

Feldman, S.R. (2015). Treatment of psoriasis. In R.D. Post (Ed.), UpToDate. Retrieved from