Discussion Post: Cultural, Spiritual, Nutritional and 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.
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ChiefComplaint (CC)
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"I came for my annual physical exam, but do not want to be a burden to my daughter."
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History of Present Illness (HPI)
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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.
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PMH
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Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis
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PSH
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S/P cholecystectomy
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Drug Hx
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Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.
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Review of Systems (ROS)
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General
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+ weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.
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Head, Eyes, Ears, Nose & Throat (HEENT)
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No changes in vision or hearing, no difficulty chewing or swallowing.
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Neck
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No pain or injury
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GU
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no urinary hesitancy or change in urine stream
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Integument
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multiple bruises on his upper arms and back.
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MS/Neuro
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+ falls x 2 within the last 6 months; no syncopal episodes or dizziness
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Objective Data
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PE
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B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
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HEENT
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Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
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Lungs
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CTA AP&L
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Card
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S1S2 without rub or gallop
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Abd
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benign, normoactive bowel sounds x 4
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Ext
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no cyanosis, clubbing or edema
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Integument
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multiple bruises in different stages of healing - on his upper arms and back.
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Neuro
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No obvious deformities, CN grossly intact II-XII
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Once you received your case number, answer the following questions:
- 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?
The response should include a reference list. Double-space, using Times New Roman 12 pnt font, one-inch margins, and APA style of writing and citations.