Annual Healthcare Visit Patient Assessment Case Study

TJ is a 25 year old postgraduate student who has come for his annual healthcare visit. He points out that he feels great and had not had any significant health-related concerns in the recent past. However, he indicates that 2 days ago, while playing football with his nephew, he sustained a “slight injury” on his foot – in his ankle area. He indicates that although he feels “some” pain on occasion, he is able to bear his weight. He points out that he expects the discomfort to ease with time.

Childhood Illnesses: bronchitis (at age 3) and conjunctivitis (at age 5). No rheumatic or scarlet fever.

Medical: Pneumonia (at age 15) – treated with amoxicillin (an antibiotic) and aspirin (pain/fever reliever). Knee fracture (at age 17) – fully recovered. Peptic ulcer disease (at age 19) – was put on cimetidine.

Screening tests: COVID-19 (July 2021) – normal.

Father died in December 2004. He was killed in combat. He was a U.S. marine serving in Afghanistan. Mother, aged 46, is still alive. She was diagnosed with hypertension and diabetes (type 2) in 2019. Condition well-managed with medications. TJ has one younger brother aged 21. His grandfather (dad’s side) died in a road accident 22 years ago. His grandfather (mom’s side) died of diabetes 27 years ago. No info on both of his grandfathers.

No family history of mental illness, epilepsy, cancer, or kidney and heart disease.

Killed in accident Died of diabetic complications.

79 83

32 46

25 21

Born and raised in Newark - NJ, was assigned male sex at birth and presently identifies as male. He is currently unemployed, pursuing a postgraduate degree. He is not married. TJ considers himself a moderate drinker and likes to hang out with friends in diverse social settings – particularly during the weekends. He does not smoke. He lives with his mum and younger brother. His mum currently works as a derivatives trader for a financial institution. She covers TJ’s financial needs. He identifies as an extrovert and whenever he is not working out, he likes to engage in outdoor activities such as hiking with friends. Although he was raised as Catholic, he presently identifies as Agnostic. TJ indicates that although he believes in a Creator, he is still on a journey to understanding the attributes and nature of the said Creator. He is comfortable with his spiritual inclination. Whenever he has something to share, he reaches out to his mom or brother and observes that his is a closely-knit family.

Exercise and diet: He regularly works out and is keen on a healthy diet. Being a keen weightlifter, he takes nutrition protein (specifically whey protein powder).

Safety measures: Describes himself as a risk taker. Would disregard conventional safety protocols in search of a thrill.

Tobacco: Denies smoking. Denies use of any illicit drug.

Sexual history: Identifies as heterosexual. Denies being sexually active at present. Denies any history of STI

General: Denies any recent change in weight. Denies fatigue.

Skin: No skin abnormalities and/or rashes.

Head, Eyes, Ears, Nose, Throat (HEENT): Head – denies headaches and has no head injury history. Eyes – denies double vision as well as cataracts. Ears – good hearing, no ringing in ears, no sign of infection. Nose – has not experienced any change in sense of smell, denies sneezing or nasal congestion. Throat – no indication of throat infection, denies any difficulties in swallowing.

Neck: Supple, No JVD or bruit.