Florida National University 23 Year Old Native American Case Study Analysis

Case 3

Case 3Subjective       Data                         Chief Complaint
(CC)

“Annual physical exam” History of Present Illness (HPI)

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.

 Drug Hx

Current Meds: deniedAllergies No allergies to food or medications.Family Hx
He has a family history of diabetes, hypertension, and alcoholism.Review of Systems (ROS) General

No recent weight gains of losses, fatigue, fever, or chills

     CV no chest discomfort or palpitations
 

 Integument

history of eczema – not activeMS/Neuro

no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements

Objective Data PE

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, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.  Lungs

CTA AP&LCard

S1S2, +II/VI holosystolic murmur; without rub or gallopAbd

benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.

Ext

no cyanosis, clubbing or edemaIntegument

intact without lesions masses or rashes.
 Neuro

No obvious deficits and CN grossly intact II-XII

Once you received your case number, 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?