MEDICAL NARRATIVE REPORT

Prepared by: [Your Name]

---

I. Patient Information

Name	George Homes
Date of Birth	January 1, 1980
Gender	Male
Address	Knoxville, TN 37901
Phone	222 555 7777

II. Chief Complaint

The patient, George Homes, a 44-year-old male, presents to the clinic with a chief complaint of persistent abdominal pain and bloating over the past week. He describes the pain as dull and constant, worsened by eating and alleviated slightly with rest. He denies any recent changes in bowel habits or urinary symptoms.

III. Past Medical History

Condition	Details
Hypertension	Diagnosed in 2010, managed with Lisinopril 10 mg daily
Type 2 Diabetes	Diagnosed in 2015, managed with Metformin 1000 mg twice daily
Asthma	Childhood-onset, occasional exacerbations, uses Albuterol inhaler as needed
Appendectomy	Surgically removed appendix in 2005

IV. Medications

Medication	Dosage	Frequency	Start Date
Lisinopril	10 mg	Once daily	May 15, 2010
Metformin	1000 mg	Twice daily	September 20, 2015
Albuterol Inhaler	As needed	PRN (as needed)	Not specified

V. Allergies

A. Medication Allergies

Penicillin: Patient experiences rash and itching.

B. Food Allergies

Shellfish: The patient experiences swelling and difficulty breathing.

C. Other Allergies

Pollen: The patient experiences seasonal allergic rhinitis.

VI. Family History and Social History

Family Member	Medical Condition
Mother	Hypertension, Diabetes
Father	Heart disease
Siblings	No significant medical history

• Social History: George Homes is a non-smoker and rarely consumes alcohol. He works as a dedicated elementary school teacher and lives with his supportive spouse and two children. He actively engages in community events and enjoys outdoor activities such as hiking and gardening.

VII. Physical Examination

A. General Appearance

George Homes gives the impression of being adequately nourished, without any immediate signs of distress or discomfort that would suggest an urgent medical issue. He is fully alert, displaying a willingness to engage and assist with the examination or conversation. Furthermore, he is oriented, meaning he clearly understands and recognizes who he is, where he is, and the current date and time.

B. Vital Signs

• Blood Pressure: 130/80 mmHg

• Heart Rate: 76 bpm

• Respiratory Rate: 16 breaths per minute

C. Abdominal Examination

• Inspection: The abdomen appears distended with mild tenderness on palpation over the right lower quadrant.

• Auscultation: Normal bowel sounds were heard in all quadrants.

• Percussion: Tympanic sound over the abdomen.

D. Additional Findings

After conducting a more thorough examination, it was determined that there was no indication of rebound tenderness or guarding. Additionally, both the liver and the spleen cannot be felt through palpation. Furthermore, there are no detectable masses or signs of organ enlargement present.

Report Templates @ Template.net