Advanced Primary Care of Family Practicum I

Clinical Case Presentations: Students must post one interesting case that he/she has seen in the clinical setting via Discussion Board in the online part of this course. The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”. In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.

Attached you will find some examples for you to have as a reference as well as the rubric. 

Don't use plagiarized sources. Get Your Custom Essay on
Advanced Primary Care of Family Practicum I
Just from $13/Page
Order Essay

Date: 02/10/2021

Patient Initials: CK

Pt. Encounter Number: 1


Sex: M

Allergies: NKA Advanced Directives: NONE



“Abdominal pain, fever, nausea and vomiting”

Mr C. K. is a 72-year-old male who visited the clinic c/o left lower abdominal pain, low grade fever, nausea and vomiting. He states that his symptoms started 2 days ago after eating dinner in one of the restaurant. Patient has a history of diabetes, hypertension, and hypercholesterolemia that are controlled with oral medications. He denies any recent trauma, epigastric pain, and constipation. Patient is a truck driver and often repairs his own truck. He stated that he did some major repairs on his truck 2 weeks ago that involve heavy lifting and hammering out old parts from the truck. He has been taking Advil 200 mg, 2 tabs in the morning and evening for his aching joints and muscles. Patient takes OTC Vitamin D, Calcium and Fish oil. He also drinks two cups of coffee daily to stay awake on the road.

Current Medications:

Lisinopril 10 mg PO daily for HTN Metformin 500 mg PO BID for Diabetes Zocor 20 mg PO daily for High cholesterol Advil 400 mg PO BID PRN for pain Vitamin D, Calcium and Fish oil PO daily


Medication Intolerances: NONE

Chronic Illnesses/Major traumas: HTN, DM, Hypercholesterolemia

Hospitalizations/Surgeries: Back Surgery in 2003

Family History:

Mother: HTN, DM, Hypercholesterolemia, and stroke. Died at age 69. Father: Arthritis, HTN, DM, CAD, COPD and ESRD.

Social History:

Truck driver, divorce, has two children and lives with girlfriend. Denies use of ETOH, but smokes 1pack cigarette per day.



Patient states he is feeling weak, has hand tremors, fever, nausea, and vomiting. Denies epigastric pain, chills and night sweats.

Weight change, fatigue, fever, chills, night sweats, energy level


Denies CP/SOB/Palpitations.
Chest pain, palpitations, PND, orthopnea, edema


Denies rash, bruising or bleeding. Denies delayed healing or changes in skin color or moles.


Denies cough/wheezing. Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB


Denies blurry visson or eye pain


Patient has nausea, vomiting and abdominal pain


Denies ear pain, hearing loss or ringing in ears.


Denies frequency, urgency, dysuria.



Denies sinus problems, nose bleeds, runny nose, throat pain, or dysphagia.


Has joint pain and stiffness daily related to repair on his truck, takes OTC Advil every AM and PM.


Denies any lumps, bumps, or changes.


Patient has weakness and hand tremors. Denies dizziness, syncope, or neurological changes.


No lymph node swelling


Denies depression, anxiety, insomnia.


Weight 220 BMI 29

Temp 99.2

BP 145/82

Height 6’1

Pulse 100

Resp 18


General Appearance

Alert and oriented; answers questions appropriately and well develop.

Skin Intact, warm and dry with no bruising, lesions, or rashes. No cyanosis or clubbing noted.


Head: Head is normocephalic, atraumatic and without lesions; hair evenly distributed.

Eyes: conjunctivae, EOM and lids are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No sclera icterus.

Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.


RRR, S1 and S2. No S3, S4 rubs, murmurs, clicks, snaps or gallops noted. No thrills, heaves, or lifts with palpation.

Peripheral Vascular: No cyanosis, clubbing. Radial pulses 3+ bilaterally. PT/DP pulse 2+ bilaterally.


Symmetrical chest expansion. Respirations regular and unlabored with diminished breath sound bilaterally. Lungs clear to auscultation bilaterally. No wheezing, rhonchi, or stridor.


Abdominal flat, soft and non-distended. Bowel sounds present in all four quadrants. Abdominal tender to left lower quadrant with palpitation.


Free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.


No bladder tenderness on palpation.


Full ROM seen in all four extremities as the patient moved about the exam room


Speech clear. Good tone. Balance stable; gait normal .


He alert and oriented x3. Patient has a normal mood and affect. His behavior is normal. Thought content normal.

Lab Tests

CBC-pending CMP-pending Stool-occult

Special Tests

CT abdomen with oral contrast


Differential Diagnoses

o 1- Gastroenteritis o 2- Colitis
o 3- Diverticulitis

o Diverticulitis

GI consultation for further evaluation
Medication: For nausea and vomiting- Zofran 4 mg SL every 6 hours as needed.

For diverticulitis – Metronidazole 500 mg TID PO plus Ciprofloxacin 500mg

BID PO for 10 days.

· Education: Diverticulitis can be caused by chronic Advil use. This wears the 
intestinal lining and can cause inflammation. 

· Non-medication treatments: High fiber diet 

· Follow-up: Return to clinic if symptoms worsen. ED precautions reviewed with 
patient. Lightheadedness, weakness, dizziness, severe abdominal pain, inability to telerate oral intake or failure to improve with outpatient management, the patient should go to nearest Emergency Room. 



Buttaro, T. M., & Sandberg_Cook, J. (2013). Primary care. A collaborative practice. St. Louis: Mosby, Inc.

Grossman, S. C., & Porth, C. M. (2014). Porth’s pathophysiology. Concepts of altered health states. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

MD, L. B. (2012). Bates’ guide to physical examination and history taking, 11th Edition. [VitalSource Bookshelf version]. Retrieved from

Patient Initials: KL

Pt. Encounter Number:1


Age: 61

Sex: Female

Allergies: KNA Advanced Directives: NONE



My blood pressure has been high lately.

61 y/o Hispanic female, who came to the consult complaining of high blood pressure readings at home during the past week. Patient states that usually the diastolic keeps higher than 140 mm/Hg, patient brought the list of the measures during the last week. Patient has four checking between 140-155mm/Hg, the systolic has been between 80 to 88 mm/Hg. Patient has previous medical history of HTN controlled with Lisinopril 5 mg PO daily. Client does not practice exercise or follows a healthy diet. She is AAO x 3, takes her own decisions, denies pain or any discomfort, denies visual or hearing issues, she is reporting good appetite and healthy sleeping, refers regular bowel movements and denies urinary discomfort.

Current Medications:

Losartan 50 mg PO daily for HTN

Essential Primary Hypertension
Mammogram: – 2018 negative
Nutrition history: – Low sodium diet
Developmental history: – Unremarkable.
Pap Smear: – 2019 negative
Blood transfusions: – Denies
Hospitalizations: – Denies
Childhood Illnesses: – Chicken pox

Family History:

mother: Deceased at 83, Heart Attack, Hypertension, Stroke father: Alive, Hypertension
sister (first): Alive, CHF
brother (first): Alive, HTN, CVA

Social History:

Tobacco: Never smoker
Alcohol: Do not drink alcoholic beverages
Drug Abuse: Denies use of illicit drugs
Safety: Household Smoke detector / Keep Firearms in home / Wear seatbelts
Sexual Activity: Not sexually active
Birth Gender: Female
Others: Place of birth – Cuba



Denies fever, chills, fatigue or weight loss. Patient has good appetite and admits sleeping well.


Denies chest pain, syncope, lightheadedness, palpitations, lower extremities edema or claudication while walking.


Denies rash, redness, ecchymosis, skin breakdown, edema, ulcer or any other skin lesion.


Denies SOB, fever, cough, hemoptysis, wheezing or cyanosis.


Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.


Denies abdominal pain, nausea, vomiting, diarrhea, constipation or blood in stools.


Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.


Denies dysuria, nocturia, frequency, incontinence, hematuria, burning or kidney stones. Denies breast discomfort or abnormal discharge from the nipples.


Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.

Patient denies joint pain, weakness, muscle pain or stiffness.

Denies any symptoms

Denies headache, weakness, seizure, dizziness, tremors, falls, numbness, paralysis or speech difficulty.

Denies any symtoms

Denies any symptoms of depression, anxiety, agitation, memory loss, forgetful, insomnia or hallucinations. Denies suicidal thoughts.


Weight 64.5 BMI







General Appearance
Patient is alert, awake, oriented x 3. Well developed, well nourished. No acute distress noted. No fevers. No weakness. Pleasant and cooperative during the examination. Head: Normocephalic, atraumatic.

Pink, intact, warm to touch, no rash, normal turgor and no abrasions.

Head: Normocephalic, atraumatic.
Eyes: PERRL. Extraocular muscle movements intact. Sclera non-icteric. Conjunctiva clear. Nose: No external lesions, mucosae non-inflamed, septum is midline.
Ears: Non-bulging and pearl bilateral TM’s. Canals free of cerumen.
Throat: Mucosa non-inflamed, no tonsillar hypertrophy or exudate.
NECK: No lymphadenopathy, No masses, midline trachea. No carotids bruit. No jugular venous distention. Proper ROM.

Regular rate and rhythm. S1 and S2 present. No murmur rubs or gallops. No S3. PMI non-displaced. No lower extremity edema. Peripheral pulses present and strong. EKG shows sinus rhythm. EKG shows sinus rhythm.

Respiratory No respiratory distress, unlabored respiratory effort, no wheezing or rhonchi, no use of accessory muscles to breathe. Vesicular murmur present bilaterally. No cyanosis.

Gastrointestinal Abdomen soft, non-tender, non-distended. No mases. Bowel sounds present in all 4 quadrants.

Soft, symmetric, no discoloration or abnormalities noted

Gynecological exam deferred today by patient. No nodules felt on breasts. No skin changes or abnormal discharge from the nipples.

No clubbing, no joint swelling. No diminished ROM. Conserved

AAO x 3. No cranial nerves deficits. No tremors, no gait imbalance, rigidity or myoclonus. No seizure activity. Strength 5 + on BUE/BLE. Tendon reflexes are intact bilaterally.

PSYCH: The patient is cooperative, no anxiety, no suicidal ideation, calmed. Affect appropriate. Good mood. No agitation or depression noted.

Lab Tests

CMP, CBC, Lipid profile, Urinalysis.

Special Tests


· Primary Diagnosis-
Differential diagnosis:

Acute pyelonephritis: Patient doesn’t complaint of back pain, urgency, fever, malodorous urine, hematuria, chills, no PMHx of kidney stones or recent respiratory infections, which makes pyelonephritis a less likely diagnosis.
Hypothyroidism: There isn’t generalized weakness, recent weight gain, cold intolerance, syncope, faintness, dry skin, anterior neck mass or pretibial edema, BMI is less than 25; which point far from Hypothyroidism diagnosis.
Hyperthyroidism: No tachycardia, no nervousness, no heat intolerance, no diarrhea, no insomnia, no, weight loss, no neck mass, no recent infections. All previously mentioned makes Hypothyroidism a less likely diagnosis.
Primary diagnosis:

1) Essential (primary) hypertension (I10): High blood pressure (BP), or hypertension, is defined by two levels by 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines: (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg. Hypertension is the most common primary diagnosis in the United States. It affects approximately 86 million adults (≥20 years) in the United States and is a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease.
Essential (primary) hypertension
Increase dose: Lisinopril 10 mg PO daily.
Low sodium diet.
Exercise 15 minutes at least 6 times a week.
Stress management or avoid stress.
Continue monitoring blood pressure at home, document and bring log to the consult.
Patient instructed to call/visit office if blood pressure higher then 140/90mm/Hg.
Avoid high-sodium foods
Avoid eating: Smoked, cured, salted, and canned meat, fish, and poultry, ham, bacon, hot dogs, and luncheon meats, regular, hard, and processed cheese and regular peanut butter. Crackers with salted tops, and other salted snack foods such as pretzels, chips, and salted popcorn. Frozen prepared meals, unless labeled low sodium. Canned and dried soups, broths, and bouillon, unless

labeled sodium-free or low-sodium. Canned vegetables, unless labeled sodium-free or low- sodium. French fries, pizza, tacos, and other fast foods. Pickles, olives, ketchup, and other condiments, especially soy sauce, unless labeled sodium-free or low-sodium.
Follow up next week to review treatment effectiveness and laboratory results.

Biondi, B., & Cooper, D. S. (2018). Subclinical hyperthyroidism. New England Journal of Medicine, 378(25), 2411-2419.
Drake, M. T. (2018, September). Hypothyroidism in Clinical Practice. In Mayo Clinic Proceedings (Vol. 93, No. 9, pp. 1169-1172). Elsevier.
Kolman, K. B. (2019). Cystitis and Pyelonephritis: Diagnosis, Treatment, and Prevention. Primary Care: Clinics in Office Practice, 46(2), 191-202.
Mancia, G. (2014). Hypertension: strengths and limitations of the JNC 8 hypertension guidelines. Nature Reviews Cardiology, 11(4), 189.


Chief Complain and pertinent history-10% of total result

Pertinent exam and Diagnosis-10% of total result

Working diagnosis and supporting criteria 5% of total result

Management plan 5% total result

Epidemiological data-cited from literature-10% of total result

Evidence based rationale for treatment (literature based)-10% of total result

Analysis of self-care and family issues related to diagnosis and treatment plan-20% of total result

Evaluation parameters to be used (or were used) to determine outcomes-10% of total result

Identify major lessons learned and how it may affect your future practice-20% of total result.

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.


Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.


Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

  • Most Qualified Writer $10FREE
  • Plagiarism Scan Report $10FREE
  • Unlimited Revisions $08FREE
  • Paper Formatting $05FREE
  • Cover Page $05FREE
  • Referencing & Bibliography $10FREE
  • Dedicated User Area $08FREE
  • 24/7 Order Tracking $05FREE
  • Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

  • On-time Delivery
  • 24/7 Order Tracking
  • Access to Authentic Sources
Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.


Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

All samples
Essay (any type)
Essay (any type)
The Value of a Nursing Degree
Undergrad. (yrs 3-4)
View this sample

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.


Happy Clients


Words Written This Week


Ongoing Orders


Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

See How We Helped 9000+ Students Achieve Success


We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

  • Clear elicitation of your requirements.
  • Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

  • Proactive analysis of your writing.
  • Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

  • Thorough research and analysis for every order.
  • Deliverance of reliable writing service to improve your grades.
Place an Order Start Chat Now

Order your essay today and save 30% with the discount code Happy