Youngstown State University

Nursing 6904 Advanced Health Assessment

History and Physical Examination Documentation Form
Tiffany Ward 4/29/2021 1600

Name: Corey Ward Age: 25 Gender: Male

Reason for Visit: Left Knee Pain

History of Present Illness

This is an office visit for this 25 year old white male steel mill worker who is in normal health
being seen today for increasing left knee pain. The left knee pain began within the last 6 days
rating the pain 8/10 that comes and goes in intensity. Patient states walking up stairs or being
exposed to the cold increases the pain and states he does not take any medication or apply heat or
ice for pain relief. Patient admits to increase in pain, denies any decrease in flexibility of joint, no
swelling or redness noted. Patient denies any infection or exposure to any hazardous materials.

Past Medical History

Chickenpox 2000, arthroscopy and meniscus repair on the left knee is 2013. Patient is up to date
on all immunizations and takes no medications. Patient has an allergy to coconuts (rash). Has
had flu shot this year.

Family History
Father alive age 40, history of diabetes and hypertension, chronic back pain. Mother alive age
45, has not past medical history. Married. No children at this time. Two siblings, two sister age
19 & 15, 19 year old stroke 2008, total hearing loss in right ear following stroke. Maternal
Grandmother has breast cancer is 2014 and 2018.

Personal / Social History

Lives in a 2 story home with his wife and two dogs, within 15 minutes of work. Occupation 1
month as steel mill worker. Patient is a veteran and served in the Navy for 5 years, 2014-2019.
States he has a very active social life at work and outside of work. Has strong family values.
Patient states he follows a general diet and has no decrease in appetite. States he is Catholic but
does not attend church.

Health Habits
States he has never smoked, cigars on occasion. Social drinker, occasional beer on the weekends
or at dinner. No use of social or street drugs. States he has trouble sleeping which began about a
year ago. Reports a “good” relationship with wife of 1 year. No problems with sexual
relationship noted. No history of STDs. No history of domestic or sexual abuse.

Mental Status: Patient is alerted and oriented to person, place, time and situation. Correctly
identifies analogies. Arithmetic calculations, writing ability, motor skills, memory, attention
span, judgment and decision making, articulation, comprehension, coherence, thought process
and perceptual distortions are all within normal limits. Voice is normal with no harsh or nasal
sound noted. Patient admits to feel anxious from time to time. Patient is calm and appears to be
in clean attire, and well groomed.

Neurological: Denies any loss of consciousness, dizziness, light-headedness, syncope, seizures,

tremors or trauma to the head. No recent fevers, difficulty with balance, swallowing, speaking or
walking. No problems with short term or long term memory or thought process. No history of
stroke, spinal cord injury, meningitis, encephalitis, or congenital disorders. All 12 cranial nerves
intact. Gait steady. No neurological deficits noted. Reflexes intact.

EENT: Denies vision difficulty, pain, strabismus, diplopia, redness or swelling of eyes,
discharge, glaucoma, use of glasses or contacts. Last vision test 2020. Denies earaches,
infections, discharge from ears, tinnitus, or vertigo. Noted hearing loss in the left ear.
Recent hearing test March 2021 Reports 1-2 colds/year. Denies nasal discharge, sinus
pain or infections, nasal trauma, allergies, epistaxis, altered smell, or polyps. Denies
bleeding gums, toothaches, hoarseness, or altered taste. Last dental exam 3 years ago.
PERRLA, Pupils symmetrical with direct and consensual light reflexes, 3 mm. Discs appear
normal upon opthlamoscopic exam. Conjunctiva clear, sclera white, moist and clear, cornea
smooth and transparent, red reflex present. 20/20 vision in left eye, 20/25 vision in right
eye. No edema noted. Able to follow commands and cardinal fields are intact. Eyebrows and
eyelashes intact.
External ear normal, free of ceremun. Bilateral tympanic membranes translucent, pearly
gray and intact. Hearing in left ear is limited. hearing in right ear intact.
Nose curves to left, nares bilaterally patent, turbinates pink, moist with no drainage
bilaterally. No lesions noted. No tenderness noted.
Lips symmetrical, smooth and pink. Teeth white, smooth and in alignment with gums.
Mucous membranes moist, pink and tongue symmetrical freely movable. Hard palate
smooth, pale, moist, immovable, soft palate smooth, pink, moist and rises. Uvula midline.
Tonsils normal. No pharyngeal irritation. No lesions noted.

Cardiovascular: Denies chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis, pallor,
edema, or nocturia. No past history of hypertension, elevated cholesterol, heart murmur,
rheumatic fever, anemia, heart disease. Exercises moderately 3 x/week, mostly walking his
two dogs daily for 30 minutes. Recent EKG done in March 2021 showed normal sinus
rhythm. Heart rate regular with 80 bpm. S1 and S2 noted, no murmurs or extra heart
sounds upon auscultation. Skin is warm and dry, skin is appropriate for ethnicity. Radial
pulse 2+, capillary refill < 3 seconds, pedal pulses 3+ with no edema noted.

Pulmonary: Denies cough, shortness of breath, environmental allergies, dyspnea,

orthopnea, or hemoptosis. No past history of frequent colds, bronchitis, pneumonia,
emphysema, asthma, tuberculosis, respiratory infections. Reports he was never a smoker
Last TB - 2014. Recent CXR in 2014 for military purposes. Trachea symmetrical and
midline. Respiratory rate 18 and regular, normal expansion no use of accessory muscles.
No crepitus upon palpation. Lung sounds clear upon auscultation. No audible sounds heard.
Diaphragmatic expansion 4 cm.
Breast: Breast equal in shape and size, color normal for ethnicity, smooth, nipple equal
bilaterally. No lumps or nodules felt upon palpation.

Gastrointestinal: Denies, nausea and/or vomiting, abdominal pain, dysphagia, hernia,

heartburn, abdominal distention or bloating, intolerances in hot or cold, blood in stool or
urine. No changes in appetite, bladder or bowel habits, food intolerance. No history of
Diabetes Mellitus, thyroid disorders, gall bladder or liver disease. No recent weight gain or
loss. Reports daily bowel movements. No family history. Abdomen is soft, symmetric and
non-tender without distention. There are stress marks noted on bilateral sides. The aorta is
midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel
sounds present and normoactive in all four quadrants. No masses, hepatomegaly, or
splenomegaly noted. Liver span 8 cm.

Integumentary: Denies any bruising, pruritis, rashes, hair loss, changes in moles,
pigmentation. No history of allergies, hives, psoriasis, eczema or other skin disorders. Skin
smooth, soft, pink, warm, dry, intact with appropriate skin turgor. Scar noted on the palm
of his left hand. States “I got stabbed”. No bruising present. No cyanosis, pallor of jaundice
present.
Nail beds pink, smooth, evenly rounded with even distribution and well groomed. No
clubbing present. Capillary refill less than 3 seconds. Scar on palm of left hand. Tattoos
noted on left upper arm, inner and outer left forearm, right outer forearm and right calf.

Renal/Urinary: Denies dysuria, urgency, frequency, penal discharge Denies UTI, STDs,
kidney stones, kidney disease, congenital disorders. No kidney tenderness upon
percussion.

Genitalia: Denies any current or history of sexually transmitted infections. No discharge

from urinary meatus. No external genital lesions. Penile shaft smooth. Testes descended
bilaterally; smooth without nodularity, induration, or masses. No tenderness along the
course of the spermatic cords, no inguinal hernia

Anus, Rectum and Prostate: Perianal area intact without lesions or visible hemorrhoids.
No fissures or fistulae. Sphincter tightens evenly. No perianal abscess felt upon palpation.
Prostate is symmetric, and smooth. Prostates protrudes 0.5 cm into the rectum. Median
sulcus present. Nontender, no nodules. Rectal walls free of masses. Moderate amount of
stool present.

Musculoskeletal: Reports pain in left knee. Denies cramps, weakness, stiffness, swelling,
warmth or heat in joints, muscles, bones. Patient had an arthroscopy and meniscus repair
on the left knee is 2013. Denies use of mobility devices. No difficulty with limited ROM or
ADLs. Crepitus heard in shoulder joint and wrist joints. All joints symmetrical and in
alignment.