Annual physical — new adult patient wellness exam
Issac Daniel Mayer · 31y · male · 2019-07-14
General examination of patient (procedure)
Chart background
Active conditions
- Received higher education (finding)
- Body mass index 30+ - obesity (finding)
- Reports of violence in the environment (finding)
- Medication review due (situation)
Active medications
None recorded
After-visit summary
Visit summary What we discussed • Medication review due • Obesity (BMI 30+) • Reports of violence in the environment / stress • Substance use • Health maintenance Next steps • Medication reconciliation completed; no active medications confirmed and recorded. • Activity prescription: three 30-40 minute runs or brisk walks weekly, daylight hours. • Snack substitution rather than restriction; standing-desk interval work encouraged. • Nutrition class referral offered; patient prefers a self-directed trial with reassessment at the next annual visit. • Depression screening ×2, assessment of anxiety, and screening for domestic abuse completed. • Supportive counseling provided; advised to return if worry escalates, sleep deteriorates, or mood symptoms persist beyond a few days. • Assessment of substance use and screening for drug abuse completed. • Low-risk counseling: no driving after use; return without judgment if use trends from choice toward need.
deterministic_extractive_v1 · not_clinically_reviewed
Clinical note
**Subjective:** Mr. Issac Mayer is a 31-year-old man presenting for a general examination, his first comprehensive visit since college. He has no acute complaints. He reports gradual weight gain attributed to a sedentary, mostly remote full-time graphic design job with frequent snacking; he runs about twice weekly, in daylight hours by preference. He describes background stress from violence in his neighborhood — shootings a few blocks away this year and a recent assault outside a nearby store; he feels safe inside his home but avoids walking late at night. He endorses occasional brief low-mood days without persistent depressed mood, anhedonia, sleep disturbance, appetite change, or loss of energy. He denies being hurt, humiliated, or made afraid by anyone. He denies chest pain, dyspnea, palpitations, abdominal pain, bowel or urinary symptoms, and unintentional weight loss. Never smoker; alcohol one to two drinks roughly twice monthly; occasional cannabis edibles a few times monthly without functional impact, driving after use, or escalation. He is single and shares a house with three roommates (four in household); works full time. No known prior diagnoses, surgeries, or hospitalizations. Medication review due addressed at this visit: he takes no prescription, over-the-counter, or supplement products regularly. No known drug allergies. Chart notable for body mass index 30+ (obesity) and reports of violence in the environment. **Objective:** BP 103/67 mmHg, HR 69/min, RR 15/min, weight 84.9 kg, height 164.3 cm, BMI 31.45 kg/m2, pain 1/10. Well-appearing, comfortable, good historian. Heart regular rate and rhythm; lungs clear; abdomen soft and nontender; no lower-extremity edema. Labs: total cholesterol 110.23 mg/dL; direct LDL 35.81 mg/dL; HDL 51 mg/dL; triglycerides 117.11 mg/dL. Screening: GAD-7 1; PHQ-2 2; HARK 0; DAST-10 2. **Assessment and Plan:** ### Medication review due Documented flag addressed at this visit. - Medication reconciliation completed; no active medications confirmed and recorded ### Obesity (BMI 30+) BMI 31.45 kg/m2 in a young adult with an otherwise favorable metabolic picture, including an excellent lipid panel (direct LDL 35.81 mg/dL). - Activity prescription: three 30-40 minute runs or brisk walks weekly, daylight hours - Snack substitution rather than restriction; standing-desk interval work encouraged - Nutrition class referral offered; patient prefers a self-directed trial with reassessment at the next annual visit ### Reports of violence in the environment / stress Chronic background neighborhood violence with adaptive precautions; he feels safe at home. GAD-7 1 and PHQ-2 2 are below clinical thresholds; HARK 0. - Depression screening ×2, assessment of anxiety, and screening for domestic abuse completed - Supportive counseling provided; advised to return if worry escalates, sleep deteriorates, or mood symptoms persist beyond a few days ### Substance use DAST-10 score 2 reflecting occasional recreational cannabis edibles; alcohol infrequent; never smoker. - Assessment of substance use and screening for drug abuse completed - Low-risk counseling: no driving after use; return without judgment if use trends from choice toward need ### Health maintenance - Influenza vaccine (split virus, trivalent, preservative-free) administered - Td (adult) tetanus toxoid booster administered; was overdue - Assessment of health and social care needs completed - Counseled against direct-to-consumer whole-body screening scans; annual follow-up visit recommended
FHIR resources at this visit
Transcript
DRIssac? Hi there, I am Dr. Okafor. Nice to finally put a face to the chart — I believe this is your first visit with us.
PTYeah, first physical since... honestly, probably since college. My roommates staged a little intervention about it after my birthday.
DRWell, happy belated birthday — thirty-one, right? And good roommates. What finally tipped the scale?
PTTurning thirty-one, mostly. And my friends keep trading articles about how guys never see a doctor until something falls off. Figured I would beat the stereotype.
DRI appreciate that. Before we dig in — anything bothering you today? Any complaints at all?
PTNot really. Maybe that I have put on weight since my desk job started. Otherwise I feel fine.
DROkay, we will definitely talk about that. Let us start with the basics. Any medical problems you have ever been told about — blood pressure, sugar, asthma, anything?
PTNothing. I have a pretty boring file, I think.
DRBoring is the goal in medicine. Any surgeries or hospital stays?
PTNever. Not even stitches.
DRMedications? Prescriptions, vitamins, supplements, anything over the counter you take regularly?
PTNothing regular. That is partly why I came — the reminder letter said a medication review was due, which felt funny since I take nothing at all.
DRHa, fair — the system flags everyone eventually. But it is actually useful: I will document officially that you have no active medications, so nothing incorrect follows you around. Any allergies to medicines?
PTNone that I know of.
DRFamily history — anything you know about? Heart disease, diabetes, cancers?
PTHonestly, nothing anyone has told me. My family is not big on talking about health.
DRNoted. Do you smoke, vape, use any tobacco?
PTNever. Cannot stand the smell.
DRAlcohol?
PTOccasionally — a drink or two if I am out with friends, maybe twice a month.
DRAny drug use — cannabis, anything else?
PTI mean... some weed now and then. Edibles mostly, a couple of times a month. Nothing beyond that.
DRThanks for being straight with me. The nurse had you fill out a questionnaire on that — you scored a two, which is on the low end, but I always ask: has it ever caused problems? Work, relationships, driving?
PTNo. It is a wind-down thing, like a glass of wine is for other people.
DRReasonable. If it ever starts feeling like a need instead of a choice, that is a conversation we can have here without judgment. Now — living situation. Who is at home?
PTI share a house with three roommates. It is chaotic but cheap, and I actually like the company.
DRAnd work?
PTGraphic design, full time, mostly remote. It pays fine. I just sit way too much.
DRSitting is the job hazard of our era. Do you have any setup that lets you stand, or is it couch-and-laptop?
PTKitchen table, mostly. I keep meaning to buy one of those standing desk risers.
DRCheap ones work fine — even alternating an hour up, an hour down changes how much you move. Now, you mentioned the neighborhood on your intake form — the reports of violence around where you live. Tell me about that.
PTYeah... there have been a couple of shootings a few blocks over this year, and someone got jumped outside the corner store last month. I am not involved in anything, but you hear it, you know? Sirens. It sits in the back of your mind.
DRThat kind of background stress is real, and it affects health. Do you feel safe inside your own home?
PTIn the house, yes. Walking home late, less so. I time my runs for daylight now.
DRThat is a sensible adjustment, honestly. The nurse also ran the mood questionnaires — twice, the short one and the spoken one, that is our routine. Your anxiety score was a one, basically minimal. The depression screen came to a two — below the level we worry about, but not a zero. Do you get down days?
PTSometimes, sure. Gray Sundays. Nothing that sticks around past a day or two.
DRSleep, appetite, energy all okay?
PTSleep is fine. Appetite is unfortunately excellent.
DRHa. And the safety questionnaire — nobody is hurting you, humiliating you, making you afraid, at home or in a relationship?
PTNo, nothing like that. I am single anyway — happily, mostly.
DRGood. Let me examine you, then we will go over your numbers... Heart sounds nice and regular. Big breath in for me... and again... lungs are clear. Lie back — any tenderness when I press here?
PTNo, that is just ticklish.
DREverything checks out. So — the numbers. Blood pressure is one-oh-three over sixty-seven, which is great. Pulse sixty-nine, breathing fifteen a minute. Height one sixty-four, weight eighty-four point nine kilos, so the body mass index comes to about thirty-one and a half, which crosses into the obese range on paper.
PTUgh. I knew the college metabolism was gone, but it stings to hear the category.
DRThe category matters less than the direction. And here is the genuinely good news — your cholesterol panel is excellent. Total cholesterol one-ten, the LDL — the bad one — around thirty-six, HDL fifty-one, triglycerides one-seventeen. Those are numbers people would trade for.
PTWait, so I am healthy on the inside but the outside needs work?
DRThat is a fair summary. And the weight is worth addressing now, at thirty-one, while it is a habits problem and not yet a disease problem. What does movement look like for you?
PTI run, when the weather and the neighborhood cooperate. Maybe twice a week. The rest is chair, screen, snacks.
DRLet us make it concrete: three runs or brisk walks a week, thirty to forty minutes, daylight hours like you already do. And look at the snacking — swap it, do not starve. I can refer you to a nutrition class if structure helps.
PTLet me try the do-it-myself version first. If my pants disagree by winter, I will take the class.
DRDeal. Two shots today, if you are willing. Your tetanus booster is overdue — the adult Td — and while I have you I would do the flu shot as well, so you are covered without another trip.
PTBoth arms, or can I keep one functional?
DROne in each is the usual, actually. A little soreness, that is all.
PTFine. My roommates will be impressed I did the whole thing properly.
DRYou should come back — not in a decade, in a year. Sooner if anything comes up. And if the neighborhood stress ever starts weighing heavier — sleep changing, worry spiraling — call us. There are good options well short of anything dramatic.
PTI appreciate that. Honestly, this was less awful than I expected.
DRI will take that review. Anything else on your mind before the nurse comes in?
PTActually, yes. Do I need any other tests at my age? My roommate keeps talking about those full-body scans.
DRSkip the scans — that is marketing, mostly. At thirty-one, with labs like yours, an annual visit, the vaccines, and honest answers on the screening forms cover you well. Save the money for good running shoes.
PTHa, done. Thanks, doc.
NURSEAll right, two quick pokes — tetanus in the left, flu in the right... and done. Keep both arms moving today and tomorrow.
PTThanks — ow — got it.
DRTake care, Issac. See you next year — not next decade.
PTNo promises. Kidding. Next year.