Patient`s M.J Age 21

Patient’s M.J





Perceptionof health: sleep difficulties, anxiety, shortness of breath, drycough.

Pastmedical history: pneumonia.

Maritalstatus: In a relationship.


Reviewof system

Generalhealth: fatigue, weakness, fever, sweats.

Head:absence of unusually frequent or a severe headache: dizziness orvertigo.

Eyes:normal vision, no eye pain, lack of double vision, absence ofscotomas (blind spots), floaters or retinal hemorrhage vs. amaurosis(fug ax).

Skin:normal skin neither color nor pigmentation. No rash or lesions.Absence of skin disease history. No loss, no significant changenails.

Nose:absence of a runny nose, occasionally nose bleeds (epistaxis).

Mouthand Throat: a toothache, occasional pain when swallowing(odynophagia).

Breasts:no dryness or discoloration. No breast pain, soreness, lumps, ordischarge, no wounds, no incisions, tumors, eczema or rashes. Nohistory of breast disease in self, mother or sister. No surgery.Self-care: does self-breast examination.

Respiratory:A dry cough, clear sputum, no wheezing, shortness of breath, exerciseintolerance, family history of lung disease, no chest pain whenbreathing, occasional cold treats with over-the-counter coughmedicine and aspirin. Occasional early morning cough which isnonproductive. A smoker never tried quitting. Lives in a poorventilated house.

Cardiovascular:Shortness of breath, no chest pain, exercise intolerance, loss ofconsciousness, no faintness, no palpitations, no claudication.

Gastrointestinal:absence of abdominal pain, no weight loss, difficulty swallowing(solids and liquids), healthy digestion, no bloating, cramping,anorexia or food avoidance. No vomiting/nausea, nodiarrhea/constipation. No obstipation, vomiting food(hematemesis).Nobright red blood per rectum(BRBPR, hematochezia), an absence offoul-smelling dark black tarry stools(melena), lack of dry heaves ofthe bowels(tenesmus).

Urinary: no micturition, dysuria, hematuria, nocturia, polyuria, hesitancy orterminal dribbling.

Genital: normal vaginal discharge, no pain. The cycle usually 28 days,duration stable, a healthy amount, no vaginal itching, discharge,sores or lesions.

Sexualhealth: in a sexual relationship with the boyfriend. This is the onlyperson she has engaged in sexual intercourse with. Uses birth controlpills to prevent pregnancy. She doesn`t use condoms. Has a feelingthe boyfriend is cheating though she hasn’t confronted him. Neverbeen tested for HIV/Aids. Not aware of any STI contact.

Menses: normal, regular, light, normal use of tampons, an absence ofstaining clothes, the lack of clots, the absence of pain.

PeripheralVascular: no pain, numbness or tingling or swelling of legs. Noulcers.

Musculoskeletal: absence of pain, misalignment or stiffness. No joint swelling, anormal range of motion.

Neurologic: change in taste, the normal sight, fresh smell, and hearing. Noseizures, no faints, no fits. No headache, occasional numbness, limbweakness, average balance, no speech problems, an absence ofsphincter disturbance.

Hematologic: absence of anemia. No history of prolonged or excessive bleedingafter dental extraction/injury. History of blood refused for blooddonation.

Endocrine:mood swings present, an absence of diarrhea, no significant weightloss. Regular food appetite. No visual disturbances. Tired,depressed. Standard voice, regular periods, occasional constipation.

Noheadaches, tongue disarticulation.

Adrenal:Absences of chronic low blood pressure, healthy skin no darkening ofthe skin in non-sun obvious places. Typical cycle duration, normalcycle frequency and the lack of vaginal bleeding irregularities. Useof birth control pills. No changes in sexual arousal or libido.

Psychiatric:depression present, abnormal sleep patterns, the presence of anxiety,difficulty concentrating, less productive in school performance, lackof energy. Change in personality. Sexual and financial binges.

ThePast Medical History

1.Pneumonia which lasted for three weeks

2.Mild depression



Livesalone in a hostel


Auntwith breast cancer.

Nobleeding history in any family member and precisely none of thepatient’s brothers and sisters

Grandfatherdied from lung disease.




Severelatex allergy with a history of anaphylaxis.


Immunizedfor flu, pneumonia, tetanus, hepatitis B, and chickenpox.

Familymedical history:

Auntdiagnosed with breast cancer.

Grandfatherdied of lung cancer.


Thepatient is 21 years old. Therefore, she fits in the intimacy vs.isolation group as per Erik Erikson. This is a stage that occurs inage’s 18-40 years. At this juncture one tends to share themselvesin an intimate manner with others. These are the relationships thatare hoped to lead a long-term commitment with someone other thanfamily members. The patient explained that she is having issues withher boyfriend. This has led to loneliness and depression (McLeod,S.A.2013. Erik Erikson). This has led to the patient developingharmful habits such as smoking and drinking alcohol. Also, this hasaffected her adult relationship with her family since she iswithdrawn.


Canadians,British, and Americans require several feet to maintain a comfortablelevel of personal space. These groups of people, need the largestpersonal space over other cultures. Therefore, the patient needs morepersonal space to open up (McNaughton, 2002)


Thepatient suffers from mental health and stress. This has beentriggered by the relationship issues, pressure from school and alsofalling sick. Also,internal factors such as hormonal functioning,physical health status, physical fitness level and mental andemotional health may be a cause. This affects the patient’s abilityto adapt to social situations, ability to demonstrate friendlycompliance: openness to experience, emotional stability, andconscientiousness (S, Guppy, and A.2004).

Inthis case, the respiratory system has to be tested since the patientshows symptoms that deal with the respiratory system considering thepatient is a smoker. This would find out more on the sputum, if it’snormal (thin, clear to white in color, and tasteless and odorless. Ifa presence of color e.g. yellow-green this would mean that there maybe a bacterial infection while rust-colored sputum is acharacteristic of pneumonia.)

Thepatient should learn the importance and efficiency of self-efficacy,which is a belief whether one can successfully engage.


Cooperativemeasures that would help the patient would include: starting withservices from trained counselors, or therapists to treat herdepression. Also, she could try joining clubs at school this way shecan connect with other people thus avoiding the feeling of beinglonely. Also, having a walk once per day would stretch her musclesthus helping her relax. About smoking, she should join one of thecommunity clubs that are helping people quit drugs. By doing thisshe would gain the ability to demonstrate friendly compliance,openness, emotional stability, and conscientiousness.


Thepatient was a 21-year-old female. She was an undergraduate, and in arelationship, the interview was slated for 2 p.m. The environment wasrelatively conducive since it was comfortably warm. She seemed pale,restless and feeble. The patient went on to explain to theinterviewer that she was having difficulty sleeping and was alsosuffering from anxiety. This had affected her daily activities sinceshe had fatigue and could not attend to her daily routine regularly.The interviewer went on to enquire how long it had occurred, and sheexplained that it was almost a week. She had a history of pneumonia.The writer then did a review of the system on her. She denied havingheadaches, dizziness or feeling lightheaded. The interviewer askedif there were any chest problems. She didn’t experience chest painsor chest tightness. Neither did she experience night sweats, chillsor fever. However, there was a presence of a dry, nonproductivecough. Also, the presence of depression, irregular sleeping patterns,difficulty in concentrating, lack of energy and change inpersonality/moods was noted. She maintained regular heat and coldtolerance. Also, she experienced shortness of breath. The interviewerlearned that the shortness of breath occurred while both at rest andwith activity. This included activities like: carrying groceries froma vehicle, having a hard time doing laundry or cleaning floors. Shefurther explained that she had breathing problems at night and thatshe had to use pillows to aid her to get in a position to breatheeasier. She was asked if she had any allergies that would interferewith her breathing, her response was negative because the patientclaimed that the only allergy she had was of latex and pollen grains.It was also noted that the patient experienced toothache andodynophagia (pain when swallowing).Interestingly, the patient had ahistory of blood being refused for blood donation. She was then askedif she smoked. Her answer was affirmative, she did. She occasionallysmoked but added that she was not much of a smoker. The intervieweralso learned that there was a family history of lung disease hergrandfather had died of lung disease.

Theinterview was successful for the patient was able to be open and evendiscussed personal issues such as stress factors affecting her thatmight be causing anxiety. The patient didn’t have a good adultrelationship with her family. She also lived alone. It was evidentshe was showing signs of withdrawal from people, which is alsoassociated with depression. She was lonely considering she was havingtrust issues in her relationship with her boyfriend. She went on toexplain how she thought he was sleeping with another person. It wassurprising for the interviewer to find out that the patient who wasin a sexual relationship with her boyfriend didn’t use condoms yetshe had doubts about him. She only protected herself from pregnancyconsidering she was not aware of S.T.I contact. Also she had nevertested for HIV/Aids. This stress factors seemed to have led her tothe harmful habits drinking and smoking. For these, the intervieweradvised the patient to join some service of help. The suggestedprograms included trained counselors, therapists, or support groups.The writer went on to explain the importance of social relationshipsfor they yield in good psychosocial health. The patient got to learnmore about the internal factors that when they get affected, they endup decreasing the wellness of anyone’s’ psychology health. Thefactors included physical fitness, mental and emotional health,hormonal functioning, and hereditary traits among others. Theinterviewer made the conversation satisfying by practicing friendlygestures which made the environment less tense and peaceful making iteasy to converse. This was by gestures such as smiling, making eyecontact, creating personal space and touch. Also, the writerpracticed active listening, critical thinking, and appropriatecommunication techniques. Both the interviewer and the patient madean emotional connection.

Theinterviewer learned that it was helpful to utilize the knowledge fromclass. For instance, it is important to understand thepathophysiology of diseases. It helps both the patient and thephysician. Examples included patient teaching and also helped thewriter understand how it could lead to other disease processes. Theinterviewer also learned that emotional connection is very efficientfor there is more of opening up. The patient may trust you more.

Atthe beginning of the interview, the atmosphere was a bit tense forthe patient was not willing to share. She had one-word answers. Butthe interviewer used friendly gestures and a warm tone which seemedto work with time. The writer felt that the patient might have liedabout some signs that she declined to have. This is because sheseemed unsure when answering.

Thewriter did not encounter any unexpected challenges

However,it was evident that the interviewer wished the patient would be sureof her answers when it came to some questions that she askedconcerning symptoms. It felt like she didn’t tell all. Thesesymptoms included denial of headaches, absence of dizziness, and nochest tightness.

Thewriter plans to practice active listening, knowledge, assessment,developmental level, appropriate communication techniques, criticalthinking, and systematic problem solving. The interviewer also planson researching more on health history so as to acquire skills to holda successful interview. Also, the interviewer has learned theimportance of a conducive comfortable room when holding this meeting.It relaxes the tension between both the patient and the interviewer.


S,Guppy, A (2001) A critical review of psychosocial hazard measures.

Physicalexamination and health assessment, seventh edition Jarvis (2016)