Medical Report

Patient: John Smith

Date of Examination: August 5, 2023
Referring Physician: Dr. Emily Johnson
Medical Record Number: 123456789
.Chief Complaint: The patient presents with persistent abdominal pain and discomfort
History of Present Illness: Mr. John Smith, a 42-year-old male, came to our clinic complain of
recurrent abdominal pain. He describes the pain as a dull ache located in the lower right quadrant of
his abdomen. the pain has been present for the past two weeks and is intermittent in nature. The
patient rates the pain as moderate, with occasional sharp exacerbations. He denies any fever, chills,
nausea, vomiting, or chang in bowel habits. The patient also notes some bloating and mild
.constipation but no significant weight loss
Medical History: Mr. Smith has a history of irritable bowel syndrome (IBS), diagnosed five years
ago. He reports occasional flare-ups of abdominal discomfort in the past, which were managed with
dietary modifications and stress-reduction techniques. he has no known allergie and is not currently
.taking any medications
Physical Examination: on physical examination, Mr, Smith appears comfortable. Abdominal
examination reveals tenderness in the right lower quadrant, without guarding or rebound tenderness.
No palpable masses are appreciated. Bowel sounds are present and normal. vital signs are within
.normal limits
Assessment and Plan: Based on the patient's history and clinical examination, it is likely that the
current symptoms are related to his known irritable bowel syndrome. however, given the location
and nature of the pain, it is prudent of rule out any other possible causes such as appendicitis or a
urinary tract infection. I have ordered a complete blood count, urinalysis, and abdominal ultrasound
.to further evaluate his condition
We will advise the patient to maintain his current dietary modifications and stress-reduction
techniques. Pending the results of the diagnostic tests, further management will be determined. The
.patient will follow up on one week to review the results and adjust the treatment plan accordingly
Dr. Jane Miller, MD Internal Medicine Specialist Date: August 5, 2023