Free Printable Physical Examination Medical Report

Patient Information

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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