NURS 6512N: Advanced Health Assessment
Week 2 Case Study: Cultural Considerations and Clinical Evaluation
Case Subject: SJ, a 28-year-old Lebanese Muslim Female
Clinical Focus: Dehydration and Orthostatic Hypotension in the context of Religious Fasting
I. Comprehensive Subjective Data
Chief Complaint (CC): "I feel like I’m going to pass out every afternoon, especially when I stand up to
pray."
History of Present Illness (HPI):
SJ is a 28-year-old female who reports a 4-day history of lightheadedness, fatigue, and "heart racing."
She is currently observing the month of Ramadan. She refrains from all food and fluids from
approximately 5:00 AM until 8:00 PM. She notes that her symptoms are mild in the morning but
become severe by 4:00 PM. She denies chest pain, shortness of breath, or actual loss of
consciousness.
Medical History:
Past Medical History: Occasional iron-deficiency anemia during pregnancy; otherwise healthy.
Surgical History: Uncomplicated C-section (2022).
Medications: Prenatal vitamin (taken sporadically).
Allergies: No known drug allergies (NKDA).
Cultural and Social History:
Language: Bilingual (Arabic and English).
Diet: Strictly Halal.
Exercise: Walking, but has stopped due to fatigue.
Modesty Preferences: SJ requests a female provider and prefers to remain covered as much
as possible during the physical examination.
II. Objective Data (Physical Examination)
Vital Signs:
Temperature: 36.9°C (98.4°F)
Respirations: 18 breaths/min
Oxygen Saturation: 99% on room air
Orthostatic Blood Pressure & Pulse:
Supine: 110/72 mmHg, HR 78 bpm
Sitting: 102/68 mmHg, HR 86 bpm
Standing (at 3 mins): 88/58 mmHg, HR 108 bpm
Week 2 Case Study: Cultural Considerations and Clinical Evaluation
Case Subject: SJ, a 28-year-old Lebanese Muslim Female
Clinical Focus: Dehydration and Orthostatic Hypotension in the context of Religious Fasting
I. Comprehensive Subjective Data
Chief Complaint (CC): "I feel like I’m going to pass out every afternoon, especially when I stand up to
pray."
History of Present Illness (HPI):
SJ is a 28-year-old female who reports a 4-day history of lightheadedness, fatigue, and "heart racing."
She is currently observing the month of Ramadan. She refrains from all food and fluids from
approximately 5:00 AM until 8:00 PM. She notes that her symptoms are mild in the morning but
become severe by 4:00 PM. She denies chest pain, shortness of breath, or actual loss of
consciousness.
Medical History:
Past Medical History: Occasional iron-deficiency anemia during pregnancy; otherwise healthy.
Surgical History: Uncomplicated C-section (2022).
Medications: Prenatal vitamin (taken sporadically).
Allergies: No known drug allergies (NKDA).
Cultural and Social History:
Language: Bilingual (Arabic and English).
Diet: Strictly Halal.
Exercise: Walking, but has stopped due to fatigue.
Modesty Preferences: SJ requests a female provider and prefers to remain covered as much
as possible during the physical examination.
II. Objective Data (Physical Examination)
Vital Signs:
Temperature: 36.9°C (98.4°F)
Respirations: 18 breaths/min
Oxygen Saturation: 99% on room air
Orthostatic Blood Pressure & Pulse:
Supine: 110/72 mmHg, HR 78 bpm
Sitting: 102/68 mmHg, HR 86 bpm
Standing (at 3 mins): 88/58 mmHg, HR 108 bpm
