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Student Resources Block format Run-on format Letter formats Samples by specialty History and Physical Well Child Checks Listen to sample medical dictation
Dough, John
DATE OF SERVICE 1/4/09
DOB:
7/11/69
HISTORY OF PRESENT
ILLNESS: Patient is here for a complete physical exam. Patient has no active or ongoing medical
problems or concerns other than the fact that he is tired a lot. Patient states that he does have some
degree seasonal affective disorder and states that he gets depressed and sleeps
a lot during the winter anyway but for the last couple of weeks he has been
having more problems than usual. He
is concerned because the weather has not really been that bad and he does not
think he should be feeling this badly.
He has also had a cough for the last 3-4 weeks this seems to be getting
better but he remains tired. He has
no distinct depressive symptoms. He
is disappointed with his laser surgeries and posterior vitrectomy of his left
eye. Dr. Jones referred him to Dr.
Smith who told him he has a cyst on his retina and he would like to try one more
laser treatment. Patient denies
that this is bothering him enough that he should be depressed about. Other pertinent information is as per
the aforementioned sheets.
PAST MEDICAL/
SURGICAL/ FAMILY/ SOCIAL HISTORY/ REVIEW OF SYSTEMS: Reviewed and recorded. See blue sheet and health history
questionnaire.
MEDICATIONS: Diamox
500 mg b.i.d.
ALLERGIES: None
known.
PHYSICAL EXAM: Height 71-1/2", weight 218 lb. BP 132/90, T 97.4o, P 74, R 18. Well developed, well-nourished, pleasant, alert, middle-aged, white male in no acute distress. For the balance of the examination please refer to the examination sheet.
ASSESSMENT:
1. Ostensibly
healthy middle-aged white male.
2. Gastroesophageal
reflux disorder.
3. Eales' disease
of the left eye.
4. History of petit
mal epilepsy, quiescent for 20 years.
5. History of
peptic ulcer disease.
6. Fatigue of
undetermined etiology, strongly suspect situation
depression.
PLAN:
I am going to check
cholesterol, HDL, glucose, TSH, and CBC.
We will advise. If these are normal
as I suspect they
will be, we will go ahead and try him on some Prozac 20 mg q.d. Risks, benefits, and
rationale behind
trying this medication was discussed.
Questions were entertained and answered to his
satisfaction. Samples for two weeks were given.
John B. Good, D.O.
/ ht:srh
Dictated Date:
1/4/09
Transcribed Date:
1/5/09