Medical Report: Patient History and Physical Report (H&P)
Patient Name: Robert Jenkins
Date: September 9, 2024
Provider: Dr. Laura Mitchell
Chief Complaint:
- New onset of abdominal pain.
History of Present Illness:
- 48-year-old male presenting with severe abdominal pain for the past 3 days. Pain is diffuse, with occasional sharp episodes. No recent changes in bowel habits.
Past Medical History:
- History of gastritis
- No prior surgeries
Medications:
- Omeprazole 20 mg daily
Family History:
- Father: Deceased (age 70) - History of colon cancer
- Mother: Age 72 - Hypertension
Social History:
- Occupation: Construction worker
- No smoking
- Drinks alcohol occasionally
Review of Systems:
- Gastrointestinal: Severe abdominal pain, nausea
- Cardiovascular: No chest pain or palpitations
- Respiratory: No shortness of breath or cough
Physical Examination:
- Vital Signs:
- Blood Pressure: 130/85 mmHg
- Heart Rate: 76 bpm
- Respiratory Rate: 18 bpm
- Temperature: 98.6°F (37°C)
- Abdominal Exam:
- Tenderness in the lower abdomen, no rebound tenderness, normal bowel sounds
Assessment:
- Suspected acute gastritis or peptic ulcer disease.
Plan:
- Order abdominal ultrasound to rule out other causes.
- Continue current medication and add an antacid.
- Recommend avoiding irritants such as alcohol and NSAIDs.
- Follow-up in 1 week to review ultrasound results and reassess symptoms.
Provider’s Signature: Dr. Laura Mitchell
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