role of clinician building health history

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


Chief Complaint
(CC)“I came for my annual physical, 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 (Previous medical history) Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis

PSH S/P cholecystectomy

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

Allergies : none

Family history: none





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.

 NeckNo pain or injury

Respiratory: none

CV, GI: None

GUno urinary hesitancy or change in urine stream

Integumentmultiple 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

HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.


CardS1S2 without rub or gallop

Abd benign, normoactive bowel sounds x 4

Ext no cyanosis, clubbing or edema

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

NeuroNo obvious deformities, 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?



at least 500 words ( 2 complete pages of content) formatted and cited in current APA style 7 ed  with support from at least 3 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%.

role of clinician  building health history


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