| “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 | |
| 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 |
| 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 |
Discussion instructions
- 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?
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
