Case 1

 

 

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):

 

 

 

Neck:

 

 

 

Respiratory:

 

 

 

CV: no chest discomfort or palpitations

 

 

 

GI:

 

 

 

GU:

 

 

 

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

 

 

 

Psych:

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

To prepare:

 

 

 

•Reflect on your experiences as a nurse and on the information provided in this week’s Learning Resources on diversity issues in health assessments.

 

 

 

•Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.

 

 

 

•Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.

 

 

 

•Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?

 

 

 

 

 

 

 

 

 

Post 1 page on : an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient above . Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks. And provide 3 current related references .

 

 

 

 

 

 

 

 

Reference

 

Readings

 

•Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. ◦Chapter 2, “Cultural Competency” (pp. 21–29)

 

 

 

•Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. ◦Chapter 1, “Clinical Reasoning, Differential Diagnosis, Evidence-Based Practice, and Symptom Analysis”

 

•Sullivan , D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis. ◦Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–36)

 

◦Appendices A–E (pp. 225–236

 

 

 

•Shaw, S. J., Huebner, C., Armin, J., Orzech, K., & Vivian, J. (2009). The role of culture in health literacy and chronic disease screening and management. Journal of Immigrant & Minority Health, 11(6), 460–467.

 

Retrieved from the Walden Library databases.