*****************Case Number 2****************
Case 1 Case 2 Case 3
Subjective Data
Chief Complaint
(CC) “I came for my annual physical exam, but do not want to be a burden to my daughter.” “I am here for my annual physical exam and have been having vaginal discharge.” “Annual physical exam”
History of Present Illness (HPI) At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs. 32-year-old pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank. 23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle.
PMH Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis
PSH S/P cholecystectomy
Drug Hx Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily. Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion Current Meds: denied
Allergies No allergies to food or medications.
Family Hx She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0. He has a family history of diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
General + weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills. No fatigue, fever, or chills. No recent weight gains of losses, fatigue, fever, or chills.
Head, Eyes, Ears, Nose & Throat (HEENT) No changes in vision or hearing, no difficulty chewing or swallowing.
Neck No pain or injury No pain or injury
Respiratory
CV no chest discomfort or palpitations
GI
GU no urinary hesitancy or change in urine stream
Integument multiple bruises on his upper arms and back. multiple piercings, and tattoos. Old scars related to “cutting” history of eczema – not active
MS/Neuro + falls x 2 within the last 6 months; no syncopal episodes or dizziness no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements. no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
Objective Data
PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8 B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98 B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6
General 23-year-old male appears well developed and well-nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress.
HEENT Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.
Lungs CTA AP&L CTA AP&L CTA AP&L
Card S1S2 without rub or gallop S1S2 without rub or gallop S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd benign, normoactive bowel sounds x 4 benign, normoactive bowel sounds x 4 benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
GU external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact.
Ext no cyanosis, clubbing or edema no cyanosis, clubbing or edema no cyanosis, clubbing or edema
Integument multiple bruises in different stages of healing – on his upper arms and back. intact without lesions masses or rashes. intact without lesions masses or rashes.
MS
Neuro No obvious deformities, CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII
Once you received your case number, answer the following questions:
- Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
- Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
- Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?