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.
Drug Hx :Current Meds: denied
Allergies: No allergies to food or medications.
Family Hx: He has a family history of diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
General: No recent weight gains of losses, fatigue, fever, or chills.
CV: no chest discomfort or palpitations
Integument: history of eczema – not active
MS/Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
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.
Lung: CTA AP&L
Card: S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
Ext: no cyanosis, clubbing or edema
Skin: intact without lesions masses or rashes.
Neuro: No obvious deficits and CN grossly intact II-XI
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. 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?