Mallory Zabor

NURS60015
Final H & P Documentation

Source and reliability: Self-referred; seems reliable.

CC: “I’m here for my annual exam.”

HPI: Mr. Sheets is a 29 y/o Caucasian, male who works for a Title Company. His last visit to
the doctor was several months ago. Patient c/o no current health issues.
PMH:
Significant Illnesses: None
Childhood illnesses: Chickenpox in childhood, denies Rheumatic fever, denies scarlett fever
Adult illnesses: None
Surgeries: None
Hospitalizations: None
Trauma: Fractured nose in childhood (As elicited later in exam)

Medications: No Prescription medications, No OTC meds, no herbal

supplements/alternative medications
Allergies: NKDA; no seasonal allergies or contact allergies, no allergies to bee
stings, no reactions to anything that he is aware of.

Immunizations: Forgot to ask -1

Family History: Maternal, grandfather (DECEASED): unsure of age or cause of death

Maternal, grandmother (ALIVE): 80, One hip uses a walker to get
around
Father, (DECEASED): 47, passed away in a fatal car crash
Mother, (ALIVE): 46, No health issues
Sister, (ALIVE): 19, Lupus

Psychosocial History: Patient works at a Title Agency, has completed some college without
completion of degree however, he does have his high school diploma. Reports that he has a
healthy home life and for leisure he enjoys the outdoors. Does not elicit any current stressors in
his life currently and reports having a good support system with his friends.
Mallory Zabor
NURS60015
Final H & P Documentation

Health Risk Factors: Denies history of smoking, vaping and reports drinking only socially.
Reports smoking weed. No environmental risks, domestic or sexual
violence, or recent travel. Reports his diet which “needs improvement”
and reports walking about 2 miles per day.

ROS:

General Survey: Denies any recent weight changes, malaise, fatigue, appetite disturbance,
sleep disturbance, fever, chills, or night sweats.

Skin: Denies lesions, pruritus, changes in texture, rashes, abnormal hair loss or
growth, tendency to bleed, ecchymosis, or changes in moles.

HEENT: Head: Denies head injury, headaches and dizziness. Eyes: Denies visual
changes, double vision, or discomfort. Denies itchy eyes and pain or
discharge. Denies wearing glasses and has never seen an eye doctor.
Ears: Denies earache, tinnitus, discharge, vertigo, hearing loss. Nose:
Denies rhinitis or nosebleeds. Fractured in childhood as elicited in
physical exam. Throat: Denies sore throat, hoarseness, sore tongue,
bleeding gums, loose, broken, or decaying teeth. Denies difficulty with
pain or swallowing. Last dental visit 6 months.

Neck: Denies lumps, swollen glands, goiter, or pain on movement.

Breasts: Denies lumps, pain or nipple discharge.
Respiratory: Denies cough, sputum, hemoptysis, dyspnea, or pleural pain.
Cardiovascular: Denies chest pain, SOB, palpitations, history of murmur, orthopnea,
intermittent claudication, or syncope. Never had EKG.
Gastrointestinal:
Denies dysphagia, nausea, vomiting, dyspepsia, hematemesis, history of
ulcers, abdominal pain, changes in stool, or rectal problems.

PV: Denies cold, numbness, pallor, hair loss, redness, swelling or tenderness in
legs. Denies color change in fingers or toes in cold weather.

Genitourinary: Denies frequency, nocturia, dysuria, incontinence, hematuria or changes in

urine color/blood in urine, or renal stones.
Mallory Zabor
NURS60015
Final H & P Documentation

Male Reproductive: Denies scrotal masses, pain, discharge, hernia, or prostate infection or
enlargement. Denies difficulty with erection or ejaculation. Does not do
self-exams.

Neurological: Denies seizures, numbness, tingling, weakness, or pain.

Musculoskeletal: Denies joint pain, redness, stiffness, swelling, decreased range of motion,
back or neck pain.
Endocrine: Denies excessive thirst or urination; heat or cold intolerance; weight gain
or loss; hair, skin, or nail changes.
Hematologic:
Denies history of transfusions, anemia, or clotting disorders.

Sexually Active, heterosexual, 1 current partner, no history of STDs.

Sexuality:
Psychiatric: Denies history of treatment for psychiatric disorders, mood swings,
hallucinations, or delusions.

Physical Exam:

General Survey: Mr. Sheets is borderline obese per BMI obtained from chart. He is a young
male, who appears generally fatigued with sluggish movements and at
times slow responses. Needs re-direction and repeated instructions at times
during exam. He is well-dressed, appears well-nourished and with
ungroomed, greasy hair and overly relaxed posture and shoulders loosely
forward, unaligned with spine over anterior body while sitting.
Vital Signs: Weight and Height per chart: Weight: 111.36 Kg, Height: 70 inches
BP: 110/80; HR: 70 beats per min.; RR 16 breaths/min.
Skin:
No rashes, lesions, clubbing of nails, petechiae, or ecchymosis. Capillary
refill < 3 sec. Skin warm and moist. No suspicious nevus.

HEENT: Head: Coarse, thick hair, appears greasy at bases. Scalp appears normal
and without lesions and dandruff. Skull normocephalic/atraumatic. Eyes:
Vision 20/20 bilaterally uncorrected, eyes tested separately bilaterally are
20/25. Visual fields full by confrontation. EOMI. Sclera white. PERRLA.
Disc margins sharp without hemorrhages or exudates. No arteriolar
narrowing or A-V nicking. Ears: External ears without erythema, pain,
lesions, or discharge. Acuity intact to whispered voice bilaterally. Weber
midline. AC>BC bilaterally. Bilateral TM clear with good cone light.
Mallory Zabor
NURS60015
Final H & P Documentation

Nose: Mucous membranes pink without erythema or drainage. Septum

midline with no perforations of the turbinates. No sinus tenderness.
Throat/Mouth: Oral mucosa pink, good dentition, pharynx without
exudates. Tongue midline. Tonsils 1+. Uvula raises midline.

Neck: Neck supple. Trachea midline. Thyroid isthmus midline. No thyromegaly.

Lymph Nodes: No cervical, axillary, tonsillar, pre-auricular, post-auricular, occipital,

submental, submandibular, or supraclavicular adenopathy.
Cardiovascular:
Carotid upstrokes brisk without bruits. Normal S1 and S2. No S3, S4,
gallops, rubs, or murmurs. No lifts, heaves or thrills. PMI is small, brisk,
and tapping, palpable in the 5th ICS 8 cm lateral to the midsternal line.

Thorax/Lungs: Thorax is symmetrical with good expansion. Respirations even and

unlabored. No crepitus. Tactile fremitus = bilaterally. Lungs resonant.
Breath sounds vesicular, without wheezing, crackles, rhonchi, or rubs.
Diaphragmatic descent 5 cm bilaterally.
Abdomen: Abdomen is flat with active bowel sounds x 4 quadrants. Percussion
tympanic throughout. It is soft, non-tender, no palpable masses, or
hepatomegaly. Liver span is 7 cm in right midclavicular line, edge not
palpable. Spleen and Kidneys not palpable. No CVA tenderness. No
femoral or abdominal bruits. Abdominal aortic width 2 cm.
GU: Circumcised male without lesions at penis, no discharge noted. Testes
without masses. No hernias. Rectal exam deferred. ENTIRE EXAM
DEFERRED

Peripheral Vascular: Extremities warm and without edema. No varicosities or stasis changes.
Calves supple and non-tender. Brachial, radial, femoral, popliteal, DP, and
PT pulses 2+ and symmetric.

Musculoskeletal: Good range of motion in all joints. No evidence of swelling, redness or

deformity. Supple musculoskeletal mass with no c/o pain upon palpation.
No neck pain with flexion, extension, or rotation.

Neurological: Mental status: Alert, relaxed, cooperative. Thought processes coherent.

Oriented to person, place, and time. Recent and remote memory intact.
New learning ability intact. Cranial Nerves: I-XII intact. Motor: Good
muscle bulk and tone. Strength 5/5 throughout. Cerebellar: finger-to-nose,
heel-to-shin intact. Gait stable. Romberg-maintains balance with eyes
closed. Sensory: Pinprick, light touch, position, and vibration intact.
Mallory Zabor
NURS60015
Final H & P Documentation

Reflexes: biceps, triceps, supinator, knee, and ankle 2+ and symmetric

with plantar flexion. Negative clonus, positive Babinski.

Assessment: Normal “annual” exam

Problem list:
1. Lack of vision care
2. Minimal care from doctor unless illness or injury (per chart)
3. Lack of basic care; including EKG
4. Lack of STD testing
5. No Self-exam practices (scrotal, annual check-ups, labs etc..)

Plan:
1) Refer patient for vision exam
2) CBC with diff, CMP (including liver panel), renal panel, lipid panel, HbA1C, TSH with
reflex to T3 and T4
3) In-office EKG for baseline
4) STD panel (blood/serum)
5) Education:
 Self-exam practices such as scrotal/Male breast exams
 Regular annual check-ups, as opposed to only MD visits for injury or illness
 Healthy diet and exercise; referral to dietician and any in-house weight-loss
programs to educate on diet and healthy exercise practices
6) Return virtual/in-person appointment for follow-up on labs and vision exam