Week 2 Health Assessment History of Present Illness Discussion Case 2 Subjective Data Chief Complaint (CC) “I am here for my annual physical

Week 2 Health Assessment History of Present Illness Discussion Case 2

Subjective Data

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Week 2 Health Assessment History of Present Illness Discussion Case 2 Subjective Data Chief Complaint (CC) “I am here for my annual physical
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Chief Complaint
(CC)

“I am here for my annual physical exam and have been having vaginal discharge.”

History of Present Illness (HPI)

32-year-old pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank.

.

PMH

PSH

Drug Hx

Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion

Allergies

.

Family Hx

She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.

Review of Systems (ROS)

General

.

No fatigue, fever, or chills.

.

Head, Eyes, Ears, Nose & Throat (HEENT)

Neck

No pain or injury

Respiratory

CV

GI

GU

Integument

.

multiple piercings, and tattoos. Old scars related to “cutting”

MS/Neuro

no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.

Objective Data

PE

B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98

General

.

HEENT

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

Lungs

CTA AP&L

Card

S1S2 without rub or gallop

Abd

benign, normoactive bowel sounds x 4

.

GU

external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact.

Ext

no cyanosis, clubbing or edema

Integument

intact without lesions masses or rashes.

MS

Neuro

No obvious deficits and CN grossly intact II-XII

No obvious deficits and CN grossly intact II-XII

Objective Data

PE

B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98

General

.

HEENT

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

Lungs

CTA AP&L

Card

S1S2 without rub or gallop

Abd

benign, normoactive bowel sounds x 4

GU

external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact.

Ext

no cyanosis, clubbing or edema

Integument

intact without lesions masses or rashes.

MS

Neuro

No obvious deficits and CN grossly intact II-XII

Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
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?

Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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