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For this Discussion, you will take on the role of a clinician who is building a health history for the following case.

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.

PMH

Hypertension   (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic   prostatitis

PSH

S/P   cholecystectomy

Drug   Hx

Current   Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and   Cipro 100mg daily.

Allergies

Family   Hx

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

Respiratory

CV

GI

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

General

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

GU

Ext

no   cyanosis, clubbing or edema

Integument

multiple   bruises in different stages of healing – on his upper arms and back.

MS

Neuro

No   obvious deformities, CN grossly intact II-XII

Answer the following questions:

Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.

Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.

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?

  
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