NURS 6512N-11: Advanced Health Assessment WEEK 2 INITIAL DISCUSSION POST # Case Study #3 Subjective Data CC: "Annual physical exam" History of Present Illness (HPI): 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. Drug Hx: Current medication - denied Allergies: no allergies to food or medications. Family history: is very positive for diabetes, hypertension, and alcoholism. Review of Systems (ROS) General: no recent weight gains of losses, fatigue, fever or chills. Head, eyes, ears, nose & throat (HEENT): CV: no chest discomfort or palpitations Integument: history of eczema – not active MS/Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements Objective Data PE: B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6 General: 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: Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, ornasopharynx clear, poor dentition – multiple carries. Lungs: CTA AP&L Cor: S1S2, +II/VI holosystolic murmur; without rub or gallop Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin. Ext: no cyanosis, clubbing or edema Integument: intact without lesions masses or rashes. Neuro: No obvious deficits and CN grossly intact II-XII Building a Health History Interviewing a patient for health history aims at improving the well-being of the patient, establish a trusting and supportive relationship, and to gather and offer information (Ball, Dains, Flynn, and Solomon, 2015). An excellent approach to the patient is important in establishing a rapport. The questions administered should be able to invite the patients’ history, expand and
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- Summer '15
- Evaluation methods, initial discussion post, annual physical exam