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 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
Family Hx
Review of Systems (ROS)
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
Objective Data
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
Submission The paper is to be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
The paper should be formatted per current APA and 400 words in length.
Formatted and cited in current APA style with support from at least 3 academic sources (LESS THAN 5 YEARS OLD)
Please use in-text APA 7th edition format citations to support all definitive statements made.
Please use SPECIFIC information, do not be general or broad, for example “Aspirin 81 mg every morning for 30 days” not “take a baby aspirin every day.”
Please use substaintive information, avoid fluff or reptition, or revision will be necessary.
Please use scholary databases like pubmed or pubmed ncbi for nursing related articles.
