For this discussion, you will take on the role of a clinician responsible for building a comprehensive health history. Your instructor will assign you a case number. Work collaboratively with your group to analyze your assigned case and respond to the discussion prompts below.
Chief Complaint (CC) : "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.
No past medical history
No past surgical history
Medication history: Current Medications: Denied.
No allergies to food or medications
Family history: Diabetes, Hypertension, Alcoholism
| General | No recent weight gains of losses, fatigue, fever, or chills. | ||
| Head, Eyes, Ears, Nose & | |||
| Neck | |||
| Respiratory | |||
| Cardiovascular | no chest discomfort or palpitations | ||
| Gastrointestinal | |||
| Genitourinary | |||
| Integument | history of eczema – not active | ||
| Musculoskeletal/Neurological | no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements | ||
| Objective Data | |||
| Physical Examination | 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. | ||
| Head, Eyes, Ears, Nose & Throat (HEENT) | Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. | ||
| Lungs | CTA AP&L | ||
| Cardiovascular | S1S2, +II/VI holosystolic murmur; without rub or gallop | ||
| Abdomen | benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin. | ||
| Genitourinary | |||
| Extremities | no cyanosis, clubbing or edema | ||
| Integument | intact without lesions masses or rashes. | ||
| Neurological | No obvious deficits and CN grossly intact II-XII |
Discussion Prompts
Based on your assigned case, collaboratively address the following:
- 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?