Consider how you would build a health history for the patient.

Case 1
Subjective Data
CC: “I came for my annual physical exam, but do not want to be a burden to my daughter.”
History of Present Illness (HPI): At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs.
PMH: hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis
PSH: S/P cholecystectomy
Drug Hx:
Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and cipro 100mg daily.
Review of Systems (ROS)
General: + weight loss of 25 lbs over the past year; no recent fatigue, fever or chills.
Head, eyes, ears, nose & throat (HEENT): no changes in vision or hearing, no difficulty chewing or swallowing.
Neck: no pain or injury
Respiratory:
CV:
GI:
GU: no urinary hesitancy or change in urine stream
Integument: multiple bruises on his upper arms and back.
MS/Neuro: + falls x 2 within the last 6 months; no syncopal episodes or dizziness
Psych:
Objective Data
PE: B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, ornasopharynx clear, edentulous.
Lungs: CTA AP&L
Cor: S1S2 without rub or gallop
Abd: benign, normoactive bowel sounds x 4
Ext: no cyanosis, clubbing or edema
Integument: multiple bruises in different stages of healing – on his upper arms and back.
Neuro: No obvious deformities, CN grossly intact II-XII
Case 2
Subjective Data
CC: “I am here for my annual physical exam and have been having vaginal discharge.”
History of Present Illness (HPI): 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 Medications: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion
Family Hx: She a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.
Review of Systems (ROS)
General: no fatigue, fever or chills.
Head, eyes, ears, nose & throat (HEENT):
Neck: no pain or injury
Respiratory:
CV:
GI:
GU:
Integument: multiple piercings, and tattoos. Old scars related to “cutting”.
Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
Objective Data
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, ornasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungs: CTA AP&L
Cor: 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; adenxa intact.
Ext: no cyanosis, clubbing or edema
Integument: intact without lesions masses or rashes.
Neuro: No obvious deficits and CN grossly intact II-XII
Case 3
Subjective Data
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 medication – denied
Allergies: no allergies to food or medications.
Family history: is very positive for diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
General: no recent weight gains of losses, fatigue, fever or chills.
Head, eyes, ears, nose & throat (HEENT):
Neck:
Respiratory:
CV: no chest discomfort or palpitations
GI:
GU:
Integument: history of eczema – not active
MS/Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
Psych:
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, ornasopharynx clear, poor dentition – multiple carries.
Lungs: CTA AP&L
Cor: S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
Ext: no cyanosis, clubbing or edema
Integument: intact without lesions masses or rashes.
Neuro: No obvious deficits and CN grossly intact II-XII
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To prepare:

Select one of the three case studies. Reflect on the provided patient information.
Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?
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Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you selected. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.

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