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Practicum Question (Answered):

Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in

mind, consider the following: Subjective: What details did the patient provide regarding his or

her personal and medical history? Objective: What observations did you make during the

physical assessment? Include pertinent positive and negative physical exam findings. Describe

whether the patient presented with any morbidities and psychosocial issues. Assessment: What

were your differential diagnoses? Provide a minimum of three possible diagnoses. List them

from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What

was your primary diagnosis and why? Plan: What was your plan for diagnostics and primary

diagnosis? What was your plan for treatment and management? Include pharmacologic and non-

pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale

for this treatment and management plan. Reflection notes: What was your “aha” moment? What

would you do differently in a similar patient evaluation?

Answer: I saw a 65-year-old male patient at the cardiology clinic for a routine follow-up. He had

a history of hypertension, hyperlipidemia, and coronary artery disease. He had undergone a

coronary artery bypass graft surgery two years ago and was taking aspirin, atorvastatin, and

metoprolol. He reported no chest pain, dyspnea, or palpitations. He smoked half a pack of

cigarettes per day and had a sedentary lifestyle.

During the physical assessment, I noted that his blood pressure was 150/90 mmHg, his pulse was

72 beats per minute, and his respiratory rate was 16 breaths per minute. His oxygen saturation

was 97% on room air. His chest auscultation revealed normal heart sounds and no murmurs,

rubs, or gallops. His lungs were clear to auscultation bilaterally. His abdomen was soft and non-