ANNUAL HEALTHCARE VISIT
The Case of Patient TJ: Annual Healthcare Visit
Initial Information
11/17/2021 9:30 AM
TJ, a 25 year old male
Source and Reliability
Reliable; self-referred
Chief Complaint
I am here for the annual physical exam.
History of Present Illness
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.
Current Medications: Whey protein powder (he is an avid weightlifter)
Allergies: NKA
Past Medical History
Childhood Illnesses: bronchitis (at age 3) and conjunctivitis (at age 5). No rheumatic or scarlet fever.
Adult Illnesses:
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.
Surgical: None
Psychiatric: None
Health Maintenance:
Immunizations: All immunizations are current
Screening tests: COVID-19 (July 2021) normal.
Family History
Father died in December 2004. He was killed...
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 (dads side) died in a road accident 22 years ago. His grandfather (moms side) died of diabetes 27 years ago. No info on...…smell, denies sneezing or nasal congestion. Throat no indication of throat infection, denies any difficulties in swallowing.Neck: Supple, No JVD or bruit.
Respiratory: No SOB, no wheezing or cough.
Cardiovascular: No discomfort, tightness or pain in the chest cavity, no edema or palpations.
Gastrointestinal: Denies nausea, vomiting as well as diarrhea. Denies abdominal pain or discomfort. Good appetite.
Urinary: Denies recent flank pain. No hematuria or dysuria. Denies recent urine odor or change in the color of urine.
Genital: normal external genitalia (i.e. from pelvic exam).
Peripheral vascular: Denies any leg pain or phlebitis pain.
Musculoskeletal: Reports mild pain in his left ankle. Denies back pain.
Psychiatric: No history of a psychiatric or mental health issues/disorder.
Neurologic: Denies recent difficulties with memory. Denies lightheadedness or dizziness. No sensory or motor loss.
Hematologic: Denies any recent blood transfusion. No easy bruising or bleeding.
Endocrine: No…
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