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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-
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