Comprehensive H and P Example

Source and reliability: Self-referred; seems reliable.
CC: “I’m here for my annual exam.”

HPI: Mr. G is a 52 yo Caucasian, male, grocery receiver who presents today for annual exam.
His last annual was in 2016. Has hyperlipidemia which he controls with diet and exercise. He
did take Lipitor for 2 years until his PCP retired and he has not had his lipids checked since
2016.
PMH:
Significant Illnesses: Hyperlipidemia since 2014.
Childhood illnesses: Chickenpox, strep throat, kidney infection age 12
Adult illnesses: None
Surgeries: None
Hospitalizations: Anaphylaxis to bee sting, 2012.
Trauma: Fractured nose age 9, playing baseball; fractured wrist age 14, fell out of a
tree.
Medications: Tylenol 650 mg PRN for headaches.
Allergies: NKDA; bee stings – anaphylaxis; fall hay-fever- runny nose and eye
itching.
Immunizations: Received all childhood vaccinations. Weekly allergy shots for

approximately one year age 13. Last tetanus shot in 2014; denies ever
receiving influenza or hepatitis B vaccinations; denies ever receiving TB
skin test.
Family History: Maternal grandfather died, age 75 of MI and was a heavy smoker.
Maternal grandmother died in her 80’s and had dementia.
Paternal grandparents unknown.
Father died at 62 from gastric cancer and had a history of treatment for
TB.
Mother died at 86 from MI and also had TIAs and CVA.
Sister died at 32 from viral pneumonia.
Sister died at 58 from cerebral aneurism and was a smoker.
Psychosocial History: Born in Cleveland, OH and raised in University Heights, OH. Resides in
Concord, OH. Graduated from H.S. and has worked as a receiver in retail
grocery for 34 years. Owns his own home, married with no children, and
describes his relationship with his wife as fine and wonderful. Leisure
activities include collecting classic films and playing piano. Works part
time for the Cleveland Cinematheque as a projectionist. Stress factors
include finances. Family and friends are sources of support.
Health Risk Factors: Denies history of smoking, alcohol, or illicit drug use. No environmental
risks, domestic or sexual violence, or recent travel. Drinks 4-6 cups of
coffee per day. Eats ice cream daily and eats out for 1-3 meals per week,
but watches his fat intake. Walks with wife 1-2 miles/day. Does not carry
an epi-pen.
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 or dizziness. Describes headaches as stress

related or from caffeine withdrawal when he does not drink coffee.
Usually bilateral, temporal. Gradual onset. Last less than 24 hours.
Relieved with Tylenol 650 mg. PRN. Eyes: Denies visual changes, double
vision, or discomfort. Has itchy eyes in the fall with hay fever.
Nearsighted and wears glasses. Last eye exam 5 years ago. Ears: Denies
earache, tinnitus, discharge, vertigo, hearing loss. Nose: Denies rhinitis
or nosebleeds. Fractured nose age 9. Fall seasonal allergies. Throat:
Denies sore throat, hoarseness, sore tongue, bleeding gums, loose, broken,
or decaying teeth. Denies difficulty with pain or swallowing. Last dental
visit 1 year ago.
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. Last EKG 2014.
Gastrointestinal: Denies dysphagia, nausea, vomiting, dyspepsia, hematemesis, history of
ulcers, abdominal pain, changes in stool, or rectal problems. Recent
occasional acid reflux, resolves without treatment.
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, or renal stones.
Male Reproductive: Denies scrotal masses, pain, discharge, hernia, or prostate infection or
enlargement. Denies difficulty with erection or ejaculation. Does self
testicular sporadically, when he thinks about it.
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, chemotherapy, or radiation therapy,
anemia, or clotting disorders.
Sexuality: Active, heterosexual, 3 lifetime partners, no history of STDs.
Psychiatric: Denies history of treatment for psychiatric disorders, mood swings,
hallucinations, or delusions.
Physical Exam:
General Survey: Mr. G is a thin, middle aged man, who is animated and responds quickly
to questions. He is a well-dressed, well nourished and groomed man
sitting comfortably on exam table.
Vital Signs: 5 ft. 5 in.; 135 lb.; BMI 22.5; BP 128/75; HR 64 beats per min.; RR 17
breaths/min.; temp 97.6
Skin: No rashes, lesions, clubbing of nails, petechiae, or ecchymosis. Capillary
refill < 3 sec. Skin warm and moist. No suspicious nevus. Callus nodule
on left anterior thigh.
HEENT: Head: Fine hair texture, male pattern balding. Scalp without lesions. Skull
normocephalic/atraumatic. Eyes: Vision 20/20 bilaterally corrected. Visual
fields full by confrontation. EOMI. Pink conjunctiva. 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. 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. JVP 1 cm above sternal angle with
HOB elevated 30 degrees. 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 8 cm in right midclavicular line, edge not
palpable. 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.
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. 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.
Good ability to calculate and reason abstractly. New learning ability intact.
Cranial Nerves: I-XII intact. Motor: Good muscle bulk and tone. Strength
5/5 throughout. Cerebellar: Rapid alternating movements, finger-to-nose,
heel-to-shin intact. Gait stable. Romberg-maintains balance with eyes
closed. Sensory: Pinprick, light touch, position, and vibration intact.
Reflexes: biceps, triceps, supinator, knee, and ankle 2+ and symmetric
with plantar flexion.
Assessment: Normal annual exam

Problem list:
1. History of hyperlipidemia
2. Bee sting anaphylaxis
3. Seasonal allergies
4. FH- gastric cancer and MI
Plan:
1. Lipid panel
2. PSA
3. TSH
4. CMP
5. Schedule Colonoscopy
6. Rx for Epi-pen
7. Education: Colon Ca screening; PSA screening; Anaphylactic reactions and the life- saving
benefit of an epi-pen; CAD and hyperlipidemia; Diet and exercise.
8. RTO in 2 weeks to review labs.

Comprehensive H and P Example

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Source and reliability: Self-referred; seems reliable.

CC: “I’m here for my annual exam.”

Medications: Tylenol 650 mg PRN for headaches.

Immunizations: Received all childhood vaccinations. Weekly allergy shots for

HEENT: Head: Denies head injury or dizziness. Describes headaches as stress

Assessment: Normal annual exam

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