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STU Patients Anxiety & Concern About Lifestyle Choices Case Discussion

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STU Patients Anxiety & Concern About Lifestyle Choices Case Discussion – Description

Answer case study 1
Discuss the specific  socioeconomic, spiritual, lifestyle, and other cultural factors related  to the health of the patient you selected. 
Describe the Subjective,  Objective, Assessment, Planning (S.O.A.P.) approach for documenting  patient data and explain what they are.
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? 

 Case 1 Case 2 Case 3   Subjective Data   Chief Complaint
(CC)  “I came for my annual physical exam, but do not want to be a burden to my daughter.”  “I am here for my annual physical exam and have been having vaginal discharge.”  “Annual physical exam”    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. 32-year-old  Hispanic/Latina pregnant lesbian – her pregnancy has been without  complication thus far. She has been receiving prenatal care from an  obstetrician. She received sperm from a local sperm bank. 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.    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. Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion Current Meds: denied    Allergies  
 
No allergies to food or medications.    Family Hx  
She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0. He has a family history of diabetes, hypertension, and alcoholism.   Review of Systems (ROS)     General  + weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills. No fatigue, fever, or chills. No recent weight gains of losses, 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  No pain or injury  
    Respiratory  
 
 
    CV  
 
 no chest discomfort or palpitations    GI  
 
 
   GU  no urinary hesitancy or change in urine stream  
 
   Integument  multiple bruises on his upper arms and back. multiple piercings, and tattoos. Old scars related to “cutting” history of eczema – not active    MS/Neuro  + falls x 2 within the last 6 months; no syncopal episodes or dizziness no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements. no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements   Objective Data     PE  B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8  B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98  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, arcus senilus bilaterally, conjunctiva and  sclera clear, nares patent, nasopharynx clear, edentulous.    Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear;  nares patent, nasopharynx clear, good dentition. Piercing in her right  nostril and lower lip.   Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares  patent, nasopharynx clear, poor dentition – multiple carries.      Lungs  CTA AP&L  CTA AP&L  CTA AP&L    Card  S1S2 without rub or gallop  S1S2 without rub or gallop  S1S2, +II/VI holosystolic murmur; without rub or gallop    Abd  benign, normoactive bowel sounds x 4  benign, normoactive bowel sounds x 4  benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.    GU  
  external genitalia intact, no lesions or masses. White copious discharge  with an amine odor; no cervical motion tenderness; adnexa intact.  
   Ext  no cyanosis, clubbing or edema  no cyanosis, clubbing or edema  no cyanosis, clubbing or edema    Integument  multiple bruises in different stages of healing – on his upper arms and back.  intact without lesions masses or rashes.  intact without lesions masses or rashes.    MS  
 
 
   Neuro  No obvious deformities, CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII

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