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.
Past medical history PHH- none
PSH- none
Drug history – denies
Allergies -none
Family history-He has a family history of diabetes, hypertension, and alcoholism.
Review of symptoms
General-No recent weight gains of losses, fatigue, fever, or chills.
Head, ears, eyes, nose, throat- none
Neck-none
Respiratoru-none
Cardiovascular-no chest discomfort or palpitations
Gi-none
GU-none
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
Objective data
Vital signs-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.
Lungs-CTA AP&L
Cariac-S1S2, +II/VI holosystolic murmur; without rub or gallop
Abdominal-benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
GU-none
Extremities-no cyanosis, clubbing or edema
Integument-intact without lesions masses or rashes
MS-none
Neuero-No obvious deficits and CN grossly intact II-XII
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?