Printable Physical Examination Medical Report

Printable Physical Examination Medical Report

Patient Information

Patient Name:

[Your Name]

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Male

Contact Information:

123-456-7890

Examination Details

  • Date of Examination: 09/30/2060

  • Time of Examination: 10:00 AM

  • Physician's Name: Dr. Emily Smith

  • Physician's Specialty: General Practitioner

  • Physician's Contact Information: (555) 123-7890

  • Referring Physician (if applicable): N/A

Medical History

  1. Chief Complaint:
    The patient reports persistent fatigue and mild headaches for the past month.

  2. Past Medical History:

    • Hypertension, diagnosed in 2020

    • Seasonal allergies

    • Appendectomy in 2000

  3. Family Medical History:

    • Father: Heart disease

    • Mother: Diabetes

    • Siblings: No significant medical history

  4. Social History:

    • Occupation: Software Engineer

    • Lifestyle Factors: Non-smoker, drinks alcohol occasionally (1-2 drinks/week), exercises 2-3 times a week (jogging and cycling).

  5. Current Medications:

    • Lisinopril 10 mg daily for hypertension

    • Cetirizine 10 mg as needed for allergies

  6. Allergies:

    • Penicillin (causes rash)

    • No known food allergies

Physical Examination Findings

  1. Vital Signs:

    • Blood Pressure: 130/85 mmHg

    • Heart Rate: 72 bpm

    • Respiratory Rate: 16 breaths/min

    • Temperature: 98.6 °F

    • Oxygen Saturation: 98%

  2. General Appearance:
    Patient appears well-nourished, in no acute distress, and is alert and oriented.

  3. Head, Eyes, Ears, Nose, Throat (HEENT):

    • Head: Normocephalic, atraumatic

    • Eyes: Visual acuity 20/20 bilaterally, no conjunctival injection

    • Ears: No discharge, tympanic membranes intact

    • Nose: No nasal obstruction or discharge

    • Throat: Pharynx clear, no lesions or erythema

  4. Cardiovascular System:

    • Heart Sounds: Regular rate and rhythm, no murmurs

    • Peripheral Pulses: Present and equal bilaterally

    • Edema: None noted

  5. Respiratory System:

    • Breath Sounds: Clear bilaterally, no wheezing or crackles

    • Respiratory Effort: Normal, no use of accessory muscles

  6. Gastrointestinal System:

    • Abdomen: Soft, non-tender, no masses palpable

    • Bowel Sounds: Normal in all quadrants

    • Palpation Findings: No organomegaly

  7. Musculoskeletal System:

    • Joint Mobility: Full range of motion in all joints

    • Muscle Strength: 5/5 in all major muscle groups

  8. Neurological Examination:

    • Cranial Nerves: All intact (II-XII)

    • Motor Function: Normal strength and coordination

    • Sensory Function: Intact to light touch and pain

  9. Skin Examination:

    • Condition: Skin warm and dry, no rashes or lesions

    • Turgor: Normal, hydrated

Assessment and Plan

  1. Summary of Findings:
    Patient exhibits mild signs of dehydration and fatigue, possibly due to sleep disturbances or lifestyle factors.

  2. Diagnosis:

    1. Hypertension (well controlled)

    2. Allergic Rhinitis

    3. Fatigue, etiology unclear

  3. Recommendations for Follow-Up or Treatment:

    • Immediate Actions: Continue Lisinopril, increase water intake, and consider lifestyle adjustments for better sleep hygiene.

    • Follow-Up Appointments: Schedule a follow-up in 1 month to reassess blood pressure and fatigue symptoms.

    • Patient Education: Discussed the importance of hydration and regular exercise. Recommended a sleep study if fatigue persists.

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