Discussion 2 Health Asess
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Case 3 |
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Subjective Data |
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Chief Complaint (CC) |
“Annual physical exam” |
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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. |
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PMH |
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PSH |
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Drug Hx |
Current Meds: denied |
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Allergies |
No allergies to food or medications. |
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Family Hx |
He has a family history of diabetes, hypertension, and alcoholism. |
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Review of Systems (ROS) |
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General |
No recent weight gains of losses, fatigue, fever, or chills. |
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Head, Eyes, Ears, Nose & Throat (HEENT) |
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Neck |
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Respiratory |
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CV |
no chest discomfort or palpitations |
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GI |
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GU |
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Integument |
history of eczema – not active |
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MS/Neuro |
no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements |
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Objective Data |
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PE |
B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6 |
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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. |
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HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. |
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Lungs |
CTA AP&L |
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Card |
S1S2, +II/VI holosystolic murmur; without rub or gallop |
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Abd |
benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin. |
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GU |
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Ext |
no cyanosis, clubbing or edema |
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Integument |
intact without lesions masses or rashes. |
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MS |
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Neuro |
No obvious deficits and CN grossly intact II-XII |