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 Asses...