Building A Health History Assignment

Building A Health History Assignment

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following case: 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 No 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 Once you received your case number, answer the following questions:

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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? Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources current ((published within the last five (5) years) scholarly journal articles)).