Annual Healthcare Visit Patient Assessment Case Study Term Paper

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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 in combat. He was a U.S. marine serving in Afghanistan. Mother, aged 46, is still alive. She was diagnosed with

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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.
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….....

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"Annual Healthcare Visit Patient Assessment Case Study" (2021, November 19) Retrieved June 6, 2026, from
https://www.aceyourpaper.com/essays/annual-healthcare-visit-patient-assessment-2183043

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