Byaruhanga adam
Apr 17
Illustrate the sample of examination report?
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Apr 17
Examination Report
Patient Name: John Doe
Date of Birth: 01/01/1990
Date of Examination: 05/15/2021
Chief Complaint: Patient presents with abdominal pain and bloating.
History of Present Illness: Patient reports experiencing abdominal pain and bloating for the past week. Pain is described as dull and constant, worsened with eating. Patient denies any recent changes in diet or medication.
Past Medical History: Hypertension, GERD, and seasonal allergies.
Medications: Lisinopril, omeprazole, and loratadine.
Allergies: None known.
Physical Examination:
- Vital Signs: BP 130/80, HR 72, RR 16, Temp 98.6°F
- General: Patient appears well-nourished and in no acute distress.
- Abdomen: Soft, non-tender, no masses or organomegaly. Normal bowel sounds present.
- Other systems: Within normal limits.
Assessment and Plan:
1. Differential diagnosis for abdominal pain and bloating includes gastritis, irritable bowel syndrome, and food intolerance. Will order blood work and stool studies to rule out infection.
2. Recommend dietary modifications and stress management techniques.
3. Follow-up in 2 weeks for review of test results and symptom improvement.
Provider: Dr. Jane Smith, MD
Date: 05/15/2021
Please note that this is a fictional example and does not represent a real patient or medical record.
Patient Name: John Doe
Date of Birth: 01/01/1990
Date of Examination: 05/15/2021
Chief Complaint: Patient presents with abdominal pain and bloating.
History of Present Illness: Patient reports experiencing abdominal pain and bloating for the past week. Pain is described as dull and constant, worsened with eating. Patient denies any recent changes in diet or medication.
Past Medical History: Hypertension, GERD, and seasonal allergies.
Medications: Lisinopril, omeprazole, and loratadine.
Allergies: None known.
Physical Examination:
- Vital Signs: BP 130/80, HR 72, RR 16, Temp 98.6°F
- General: Patient appears well-nourished and in no acute distress.
- Abdomen: Soft, non-tender, no masses or organomegaly. Normal bowel sounds present.
- Other systems: Within normal limits.
Assessment and Plan:
1. Differential diagnosis for abdominal pain and bloating includes gastritis, irritable bowel syndrome, and food intolerance. Will order blood work and stool studies to rule out infection.
2. Recommend dietary modifications and stress management techniques.
3. Follow-up in 2 weeks for review of test results and symptom improvement.
Provider: Dr. Jane Smith, MD
Date: 05/15/2021
Please note that this is a fictional example and does not represent a real patient or medical record.
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