Medical Report: Patient History and Physical Report (H&P)

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 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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Patient's Initial Assessment Report: Example 2

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Medical Report: Progress Note 1

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Patient Name: Emily Carter Date: September 9, 2024 Provider: Dr. Michael Lewis Visit Type: Follow-up Chief Complaint: Follow-up for management of asthma and recent exacerbation. Subjective: Patient reports improvement in asthma symptoms since starting new inhaler. However, occasional wheezing at night persists. Objective: Vital Signs: Blood Pressure: 118/76 mmHg Heart Rate: 80 bpm Respiratory Rate: 16 bpm Temperature: 98.2°F (36.8°C) Respiratory Exam: Breath sounds clear bilaterally, occasional wheezing noted in the right lower lung field. Medication Adherence: Adheres to new inhaler regimen but reports occasional missed doses. Assessment: Asthma symptoms partially controlled with current medication. Persistent nocturnal wheezing may indicate suboptimal control. Plan: Continue current inhaler therapy. Increase the frequency of the use of the inhaled corticosteroid. Educate patient on proper inhaler technique and the importance of regular use. Schedule follow-up appointment in 4 wee
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