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Case 1 Subjective Data

August 28, 2024

	Case 1
Subjective Data
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

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.
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?

Submission Instructions:

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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Case 1 Subjective Data

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