Take on a role of a clinician who is building a health history for the following case:
Subjective
Chief Complaint: Annual physical exam
History of Present Illness (HPI): 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.
Past Medical History (PMH):
Past Surgical History (PSH):
Drug Hx: Denies any meds
Allergies: NKA
Family Hx: He has a family history of diabetes, hypertension and alcoholism
Review of Systems
General: No recent weight gains or loss, fatigue, fever, or chills
(HEENT):
Neck:
Respiratory:
CV: no chest discomfort or palpitations
GI:
GU:
Integument: hx of eczema – not active
MS/Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns: no twitches or abnormal movements
Objective Data
PE: 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, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.
Lungs: CTA AP&L
Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
GU:
Ext: no cyanosis, clubbing or edema
Integument: intact without lesions masses or rashes.
MS:
Neuro: No obvious deficits and CN grossly intact II-XII
- 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?
500 words, APA style, 2 academic resources
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