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Case#2 Chief complaint: “I am here for my annual physical exam and have been having vaginal discharge.” History of Present illness: 32-year-old

August 28, 2024

Case#2

Chief complaint: “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 history: She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.

General: No fatigue, fever, or chills.

Neck: No pain or injury

Integumentary: multiple piercings, and tattoos. Old scars related to “cutting”

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

Abdominal: 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

Integumentary: intact without lesions masses or rashes.

Neuro: No obvious deficits and CN grossly intact II-XII

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?

Submission Instructions:

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

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