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 weeks to assess control and review asthma action plan.

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Patient's Initial Assessment Report: Example 2

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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 Assessmen
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