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 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
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.
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:
1. Discuss
the specific socioeconomic, spiritual, lifestyle, and other cultural factors
related to the health of the patient you selected.
2. Describe
the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for
documenting patient data and explain what they are.
3. 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?
Submission
Instructions:
·
Your initial post should be 500 words, formatted and cited
in current APA 7th style with support from at least 3 academic sources.
·
Turnitin similarity should be less than 14%
·
Quotes “…” cannot be used at a higher learning level for your
assignments, so sentences need to be paraphrased and referenced.
·
Acceptable references include scholarly journal articles or
primary legal sources (statutes, court opinions), journal articles, and books
published in the last five years. No websites to be referenced without
prior approval.
Textbook(s)
1. Rhoads, J., Demler, T. L., & Dlugasch, L. (2021). Advanced health
assessment and
diagnostic reasoning (4th ed.). Jones & Bartlett Learning.
ISBN: 9781284170313
Assessment of the Whole Person
Read
·
Rhoads, J., Demler, T. L., & Dlugasch, L. (2021). Advanced health assessment and diagnostic
reasoning. Jones and Bartlett Learning.
·
Chapters 1-6
·
Jarvis, C. (2016). Physical
examination & health assessment (7th ed.). Elsevier.
ISBN: 9781455728107
·
Maria T. Codina Leik N-C, A. (2017). Family nurse practitioner
certification intensive review: Fast facts and practice questions (3rd ed.). Springer
Publishing Company.
·
Fitzgerald, A. M. (2017). Nurse practitioner certification examination and practice
preparation. F.A. Davis Company.
ISBN: 978-0803660427
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