I am here for my annual physical exam and have been having vaginal discharge.” History of Present Illness (HPI): 32-year-old Hispanic/Latina 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.
Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion
She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.
Review or systems:
No fatigue, fever, or chills. No pain or injury. multiple piercings, and tattoos. Old scars related to “cutting”. no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.
B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. CTA AP&L. S1S2 without rub or gallop, benign, normoactive bowel sounds x 4.
external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact. no cyanosis, clubbing or edema. intact without lesions masses or rashes. No obvious deficits and CN grossly intact II-XII
- Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
- Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
- 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?Your initial post should be at least 500 words With at least 2 academic references