For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Case 1Case 2Case 3Subjective DataChief 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 Hispanic/Latina 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.PMHHypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis PSHS/P cholecystectomy Drug HxCurrent 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 occasionCurrent Meds: deniedAllergies No allergies to food or medications.Family HxShe 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. NeckNo pain or injury No pain or injury Respiratory CV no chest discomfort or palpitationsGI GUno urinary hesitancy or change in urine stream Integumentmultiple bruises on his upper arms and back.multiple piercings, and tattoos. Old scars related to “cutting”history of eczema – not activeMS/Neuro+ falls x 2 within the last 6 months; no syncopal episodes or dizzinessno 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 movementsObjective Data PEB/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98B/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. HEENTAtraumatic, 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. LungsCTA AP&LCTA AP&LCTA AP&LCardS1S2 without rub or gallopS1S2 without rub or gallopS1S2, +II/VI holosystolic murmur; without rub or gallopAbdbenign, normoactive bowel sounds x 4benign, normoactive bowel sounds x 4benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.GUexternal genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact. Extno cyanosis, clubbing or edemano cyanosis, clubbing or edemano cyanosis, clubbing or edemaIntegumentmultiple 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 NeuroNo obvious deformities, CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XIINo 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.
Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
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?
