healthassesmentmodule2disscusion.docx
Case study
Chief Complaint (CC)
“I am here for my annual physical exam and have been having vaginal discharge.”
History of Present Illness (HPI)
32-year-old 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.
PMH
PSH
Drug Hx
Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion
Allergies
Family Hx
She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.
REVIEW OF SYSTOM
General
No fatigue, fever, or chills.
Head, Eyes, Ears, Nose & Throat (HEENT)
Neck
No pain or injury
Respiratory
CV
GI
GU
Integument
multiple piercings, and tattoos. Old scars related to “cutting”
MS/Neuro
no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.
Objective data
PE
B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98
General
HEENT
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungs
CTA AP&L
Card
S1S2 without rub or gallop
Abd
benign, normoactive bowel sounds x 4
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
Integument
intact without lesions masses or rashes.
MS
Neuro
No obvious deficits and CN grossly intact II-XII
Cultural, Spiritual, Nutritional, & Mental Health Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
2. Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
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 at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
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