CHIEF OF COMPLAIN: “I am here for my annual physical exam and have been having vaginal discharge.”

CASE # 2 

 Subjective Data 

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.
 

OBJECTIVE DATE:

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:

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 patients 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?