Nursing Health Assessment

Case 1 Case 2 Case 3 Subjective Data Chief “I came for my annual physical Complaint exam, but do not want to be a (CC) 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) 23-year-old Native American male comes in to see you because At-risk 86-year-old Asian male – 32-year-old pregnant lesbian – he has been having anxiety and who is physically and financially her pregnancy has been without wants something to help him. He dependent on his daughter, a complication thus far. She has has been smoking “pot” and says single mother who has little time been receiving prenatal care from he drinks to help him too. He or money for her father’s health an obstetrician. She received tells you he is afraid that he will needs. sperm from a local sperm bank. 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 Current Meds: denied counter for aches and pains on occasion No allergies to food or medications. She has a strong family history of He has a family history of diabetes. Gravida 1; Para 0; diabetes, hypertension, and Abortions 0. alcoholism. Nursing Health Assessment

Allergies Family Hx 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, No changes in vision or hearing, Ears, Nose no difficulty chewing or & Throat swallowing. (HEENT) Neck No pain or injury No pain or injury Respirator y CV no chest discomfort or palpitations GI no urinary hesitancy or change in urine stream multiple bruises on his upper multiple piercings, and tattoos. Integument arms and back. Old scars related to “cutting” no syncopal episodes or + falls x 2 within the last 6 dizziness, no change in memory MS/Neuro months; no syncopal episodes or or thinking patterns; no twitches dizziness or abnormal movements. GU history of eczema – not active no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements Objective Data PE General HEENT B/P 188/96; Pulse 89; RR 16; B/P 128/76; Pulse 83; RR 16; B/P 158/90; Pulse 88; RR 18; Temp 99.0; Ht 5,6; wt 110; BMI Temp 99.0; Ht 5,6; wt 128; BMI Temp 99.2; Ht 5,7; wt 208; BMI 17.8 20.98 32.6 23-year-old male appears well developed and well-nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress. Atraumatic, normocephalic, Atraumatic, normocephalic, Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva PERRLA, EOMI, arcus senilus PERRLA, EOMI, sclera with and sclera clear; nares patent, bilaterally, conjunctiva and sclera mild icterus, nares patent, nasopharynx clear, good clear, nares patent, nasopharynx nasopharynx clear, poor dentition dentition. Nursing Health Assessment

Piercing in her right clear, edentulous. – multiple carries. nostril and lower lip. Lungs CTA AP&L CTA AP&L Card S1S2 without rub or gallop S1S2 without rub or gallop Abd benign, normoactive bowel sounds x 4 benign, normoactive bowel sounds x 4 S1S2, +II/VI holosystolic murmur; without rub or gallop benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin. external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact. GU Ext CTA AP&L no cyanosis, clubbing or edema no cyanosis, clubbing or edema no cyanosis, clubbing or edema multiple bruises in different Integument stages of healing – on his upper arms and back. intact without lesions masses or rashes. intact without lesions masses or rashes. No obvious deficits and CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII MS Neuro No obvious deformities, CN grossly intact II-XII … Nursing Health Assessment