The patient is a male African American from the state of Indiana. He is 25 years old and he speaks
English and French. It is therefore easier to communicate with him because of the fact that he is
familiar with the English language, which is spoken by most of the people in the United States of
America. He does not have any special communication needs which means that it is easier to
understand him and just by talking to him. He is also educated and is a good reader as well as a good
speaker and is able to communicate clearly. He is a student in the school of education in one of the
popular colleges in the United States of American which means that he will be graduating soon and
will be able to take up his career in teaching and have an impact on the society. Routine medical
checkups are important because they enable a person to live a healthy life.
The patient has come to seek healthcare because he has been feeling persistent chest pains that
have become uncomfortable in his life. He says that he usually feels some slight pain on the right
side of the chest which is a condition that has made him frustrated and has robbed him of comfort.
The sickness started in the year 2017 after he visited Asia. Since then, he has been feeling some
chest pains that has made it hard for him to concentrate on his daily activities which is the main
reason why he chose to seek medical care.
Looking at his past medical history, there is a time when he suffered from Pneumonia which made
him to be admitted to the hospital as a young man. He has been immunized against several diseases
when he was a child as recommended by the ministry of health especially the department that
focuses on immunization. One of the main suspected medical conditions that are bedeviling him is
pneumonia because he has ever been infected before meaning that the disease is able to affect him
again. It is therefore important to screen the patient for pneumonia as a way of ruling out the
conditions before they make a decision of conducting more tests on the patient to ascertain the real
medical condition that is affecting him.
The patient does not have any known allergies but more tests will be needed to ascertain the fact
that he does not have allergies and that they are not the cause of the medical condition that he is
The patient used Macrolide antibiotics in the treatment of Pneumonia when he was admitted when
he was 12 years old. Since then he has not been on any medication apart from paracetamol that he
has been using periodically to relieve headaches especially after he had worked for a really long time
or when he just felt a headache.
All his parents and siblings are alive and his grandparents died as a result of old age meaning that it
hard to trace the disease that he has to his family history.
The patient is a highly reserved person who loves to stays indoors and most of the times he prefers
to stay indoors instead of being with the other people. However, he is a very good company when
with the other people and peers. He does not have a history of alcohol and substance abuse. He is a
staunch Christian who believes in living a good and healthy life as a way to good health.
The patient is fine despite the incessant chest pains that he is experiencing in his life. All the other
parts of the body seem to be okay unless the diagnosis says otherwise. He has no record of high
blood pressure and his body temperature usually gets higher than normal in case he has a fever.
Integumentary assessment shows that the patient has a good skin and appendages. However, he
has one scab that came as a result of a fall. However, it is unlikely that the scab has anything to do
with the chest pains that he is feeling.
He notes periodic headaches, the eyes do not have cataracts and they have a good vision according
to him, his nose is fine because he is able to smell the things that are found in the environment. No
throat pains noted.
No problems have been recorded in the neck and the thyroid.
There are no recorded complaints in the breasts and the axillary lymph nodes.
There is a history of pneumonia that affected the respiratory, Cardiovascular and the Peripheral
vascular system in the body.
No problem has been recorded in the gastrointestinal system, genitourinary system, sexual health,
the endocrine system, neurological system. The hematological system has a history of being affected
In the functional assessment, it can be noted that the patient has a high self-esteem, he lives a very
active physical life, he gets enough sleep and nutrition and has not history of malnutrition. He also
has good interpersonal relationship with people in the society, he goes to church for spiritual
nourishment, Knows how to deal with stress, does not have a history of drug taking.
One notable thing is the fact that the patient has been periodically exposed to cold conditions which
may have contributed to the chest pains that he is facing presently.
Environment/Hazards: Exposure to cold environment.
Intimate partner violence: none
Occupational health: Observant
Perception of health: Good
Developmental Competence – children, pregnant women, older adult: No record.