Medical Narrative Report
MEDICAL NARRATIVE REPORT
Prepared by: [Your Name]
I. Patient Information
|
Name |
John Doe |
|
Date of Birth |
January 1, 1980 |
|
Gender |
Male |
|
Address |
123 Main Street, Anytown, USA |
|
Phone |
(555) 123-4567 |
II. Chief Complaint
The patient, John Doe, 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: John Doe 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
John Doe 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.
