CASE # 2
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CHIEF OF COMPLAIN: “I am here for my annual physical exam and have been having vaginal discharge.”
HISTORY OF PRESENT ILLNESS: 32-year-old 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.
DRUG HX: Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion
FAMILY HX: She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.
REVIEW OF SYSTEM:
GENERAL: No fatigue, fever, or chills.
NECK: No pain or injury
INTERGUMENTARY: multiple piercings, and tattoos. Old scars related to “cutting”
MS/NEURO: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.
PE: B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
LUNGS: CTA AP&L
CARDIO: S1S2 without rub or gallop
ABD: benign, normoactive bowel sounds x 4
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
INTERMENT: intact without lesions masses or rashes.
NEURO: No obvious deficits and CN grossly intact II-XII
Answer the following questions:
- Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
- Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
- 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?
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