Case Report about an Interview with a Healthy Person

Patient Data 

Name: Alex Monroe 

Age: 27 

Sex: Female 

The First Meeting and Impressions 

There was a brief introduction between the physician and the patient. The patient was made to understand that she will be treated with respect as a unique patient. The patient displayed some form of anxiety during the initial encounter. She seemed rather uneasy and worried. The physician had to calm her down by assuring her that everything would be alright. It was easy to tell that the patient was in some pain and discomfort. 

The First/Initial Interview. 

Exploration 

The physician asked the patient how she was feeling. He asked whether she felt comfortable and was in a position to talk. The patient assured the doctor that she was not in a very critical condition but had some discomfort. The physician inquired about the problems that brought the lady to the hospital. The patient complained of experiencing abdominal pain and cramping the previous night. She mentioned other symptoms like rectal pain, diarrhea, passing a small amount of blood with stool, and fever. The physician wanted to know the severity of the pain, and so he engaged the patient in a series of inquisitive questions. The patient specified that she experienced short periods of sharp abdominal pain and longer periods of dull abdominal and rectal pain. 

Present Complaints 

The patient at the moment complained of dull pain in the abdomen, which recurred after some time. She also complained of general body weakness and fatigue. The patient reported that she could not stand up for more than ten minutes because of weak joints and fatigue. The patient seemed dehydrated and like she had lost weight. She had a bottle of water with her, which she said was essential, especially at that time because she felt thirsty most of the time. The fever she had the previous night had gone down significantly since that morning. 

Biographical essay, important life events 

Alexis was born after thirty-five weeks, normally with no complications. Her birth weight and head circumference were okay for a newborn baby. She was born a healthy kid. She received all the vaccines and preventive drugs that are essential during development and growth. Alexis was raised by both her father and mother. She developed gradually, going through all the stages of mental development (cognitive) and physical development. She started school at the age of four years, and she exuded signs of a brilliant student from early on. As she grew up, she became more social and established social relationships at school, in church, and with the neighbors. She excelled in her studies and went to college, where she pursued a degree in Economics and Statistics. Her hard work, dedication, and commitment made her earn recognition from her bosses in the workplace. She is currently working as the assistant manager at a local insurance firm. She lives with her fiancé, and they plan to get married in a year. 

Interest(s), way of spending leisure time, hobbies. 

Alexis loves sports, mostly lawn tennis, and badminton. She also loves reading novels: thrillers, romantic and political novels. She enjoys taking bike rides with her friend during her free time. In addition to that, she also loves baking and trying new recipes. 

She experienced the lowest moment of her life when she lost her best friend while in high school. Her friend has succumbed to asthma at a very young age. She had to undergo therapy for some time to help her reconnect with reality. 

Summary 

Overall, the patient's background does not point to the possibility of a hereditary or inherited disease. She had a normal development and growth process. However, the symptoms showed a need for further tests to be conducted to ascertain the root of the problem.