Discussion Post Module One NUR 504 Advanced Health Assessment

Module 1 Discussion: Cultural, Spiritual, Nutritional, & Mental Health Disorders

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.

Subjective Data

Chief Complaint (CC)

1. I came for my annual physical exam, but do not want to be a burden to my daughter.
2. I am here for my annual physical exam and have been having vaginal discharge.”
3. Annual physical exam”

History of Present Illness (HPI)

1. 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.
2. 32-year-old Hispanic/Latina 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.
3. 23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle.

PMH

1. Hypertension (HTN)
2. Gastroesophageal reflux disease (GERD)
3. b12 deficiency and chronic prostatitis

PSH

1. S/P cholecystectomy
2. N/A
3. N/A

Drug Hx

1. Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.
2. Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion
3. Current Meds: denied

Allergies

1. N/A
2. N/A
3. No allergies to food or medications.

Family Hx

1. N/A
2. She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.
3. He has a family history of diabetes, hypertension, and alcoholism.

Review of Systems (ROS)

General

1. weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.
2. No fatigue, fever, or chills.
3. No recent weight gains of losses, fatigue, fever, or chills.

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

1. No changes in vision or hearing, no difficulty chewing or swallowing.
2. N/A
3. N/A

Neck

1. No pain or injury
2. No pain or injury
3. N/A

Respiratory

CV

1. N/A
2. N/A
3. no chest discomfort or palpitations

GI

GU

1. No urinary hesitancy or change in urine stream
2. N/A
3. N/A

Integument

1. Multiple bruises on his upper arms and back.
2. Multiple piercings, and tattoos. Old scars related to “cutting”
3. History of eczema – not active

MS/Neuro

1. Falls x 2 within the last 6 months; no syncopal episodes or dizziness
2. No syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.
3. No syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements

Objective Data

PE

1. B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
2. B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98
3. B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6

General

1. N/A
2. N/A
3. 23-year-old male appears well developed and well-nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress.

HEENT

1. Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
2. Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
3. Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.

Lungs

1. CTA AP&L
2. CTA AP&L
3. CTA AP&L

Card

1. S1S2 without rub or gallop
2. S1S2 without rub or gallop
3. S1S2, +II/VI holosystolic murmur; without rub or gallop

Abd

1. benign, normoactive bowel sounds x 4
2. benign, normoactive bowel sounds x 4
3. benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.

GU

1. N/A
2. External genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact.
3. N/A

Ext

1. no cyanosis, clubbing or edema
2. no cyanosis, clubbing or edema
3. no cyanosis, clubbing or edema

Integument

1. multiple bruises in different stages of healing – on his upper arms and back.
2. intact without lesions masses or rashes.
3. intact without lesions masses or rashes.

Neuro

1. No obvious deformities, CN grossly intact II-XII
2. No obvious deficits and CN grossly intact II-XII
3. No obvious deficits and CN grossly intact II-XII

Once you received your case number, answer the following questions:

1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related
   to the health of the patient you selected.
2. Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
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?

Discussion Submission Instructions:
Your instructor will assign you your case number and you will post on the case number you
have been assigned.
You will reply to the other two case studies (One of each).
Your initial post should be at least 500 words, formatted and cited in current APA style with
support from at least 2 academic sources. Your initial post is worth 8 points.
You should respond to at least two of your peers by extending, refuting/correcting, or adding
additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
All replies must be constructive and use literature where possible.
Please post your initial response by 11:59 PM ET Thursday, and comment on the posts of two classmates by 11:59 PM ET Sunday.
You can expect feedback from the instructor within 48 to 72 hours from the Sunday due date.