Health Assessment Discussion 2 - History of Present Illness (HPI) 

Health Assessment Discussion 2

Case 1

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            

 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

 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

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.

Answer the following questions about your specific case number assigned:

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 patient 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?

Your initial post  should be at least 500 words, formatted and cited in the current  APA style with support from at least  3 academic sources.