Report 09.01 Office Note (History and Physical)

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OFFICE NOTE
HISTORY AND PHYSICAL PATIENT
NAME:
Jim Andrews
DATE:
01/30/20XX
HISTORY OF PRESENT ILLNESS
This patient was discharged from the hospital last week after 1-week admission for myocardial
infarction. He has been feeling well since discharge.
PHYSICAL EXAMINATION
VITALS: Blood pressure 145/85. Heart rate 72. Respiration 16. Temperature 98.2.
HEIGHT: 5 feet 4 inches.
WEIGHT: 165 lbs.
APPEARANCE: Slightly overweight, robust.
HEENT: Within normal limits.
NECK: Within normal limits. No palpable thyroid.
CHEST: Well formed.
LUNGS: Clear in all lungs fields on auscultation.
HEART: Normal sinus rhythm and no murmur.
ABDOMEN: Within normal limits. No palpable masses.
LIVER: Not palpable.
SPLEEN: Not palpable.
GU: Within normal limits.
EXTREMETIES: Within normal limits.
NEURO: Grossly intact.
IMPRESSION
Status post myocardial infarction.
PLAN
1. Continue same medications.
2. Increased ambulation at home. At Happy, Heart Health Center begin walking on treadmill at
level 1 for 5 minutes and increasing every 3 days by 5 minutes for one week.
3. May return to work in 2 weeks. Return 2 weeks.
______________________________
Megan Lewis, MD
Ellen Sterrett
Report 09.01
Office Note
History and Physical
OFFICE NOTE
ML/ES
D: 01/30/2XX
T: 01/30/20XX
C: Sandra Southwood, MD
Ellen Sterrett
Report 09.01
Office Note
History and Physical
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