Take on the role of a clinician who is building a health history
Case 1
Chief Complaint ” came for my annual physical , but do not want to be a burden to my daughter.”
The illness’s past and present (HPI) Asian man, 86 years old, who is at risk; he is financially and physically dependent on his daughter, a single mother with few resources to meet her father’s medical demands.
prior medical history
Chronic prostatitis, hypertension (HTN), GERD (gastric reflux illness), and b12 deficiency
Cholecystectomy PSHS/PMedication HxCurrent: 100 mg of Cipro day, 20 mg of Prilosec daily, monthly B12 injections, and 10 mg of Lisinopril daily.
Allergies: none
Family Hx
Review of Systems (ROS)
General
+ weight loss of 25 lbs over the past year; no recent 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 Respiratory
CV
GI
GU
no urinary hesitancy or change in urine stream Integument
multiple bruises on his upper arms and back.
MS/Neuro
+ falls x 2 within the last 6 months; no syncopal episodes or dizziness
PE
B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt110; BMI 17.8
General
HEENT
Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Lungs
CTA AP&L Card
S152 without rub or gallop
Abd
benign, normoactive bowel sounds x 4 GU
Ext
no cyanosis, clubbing or edema Integument
multiple bruises in different stages of healing – on his upper arms and back. MS
Neuro
No obvious deformities,
CN grossly intact II-XII
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?
Submission Instructions:In 500 words, formatted and cited in current APA style with support from at least 2 academic sources within 5 years.
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