Medical Report

Patient: John Smith Remove unnecessary space :Commented [MA1]

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 Commented [MA2]: Replace with
recurrent abdominal pain. He describes the pain as a dull ache located in the lower right quadrant
complaining
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, Commented [MA3]: In nature may be redundant.
nausea, vomiting, or chang in bowel habits. The patient also notes some bloating and mild
:Commented [MA4]
constipation but no significant weight loss. Correct the subject-verb agreement

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 Commented [MA5]: Correct your spelling
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 Commented [MA6]: Change preposition
urinary tract infection. I have ordered a complete blood count, urinalysis, and abdominal ultrasound
to further evaluate his condition. It seems the preposition use may be incorrect here.

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 Commented [MA7]: Change preposition
accordingly.
It seems that preposition use may be incorrect here.
Dr. Jane Miller, MD Internal Medicine Specialist Date: August 5, 2023