Case #1
Subjective Data
Chief Complaint
(CC)
“I came for my annual physical exam, but do not want to be a burden to my daughter.”
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.
Past Medical History (PMH)
Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis
Past Surgical History (PSH)
S/P cholecystectomy
Drug Hx
Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.
Allergies
NKA
Family Hx
None
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
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
Objective Data
PE
B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
HEENT
Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous
Lungs
CTA AP&L
Card
S1S2 without rub or gallop
Abd
benign, normoactive bowel sounds x 4
Ext
no cyanosis, clubbing or edema
Integument
multiple bruises in different stages of healing – on his upper arms and back.
Neuro
No obvious deformities, 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. 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