Patient's Initial Assessment Report: Example 1

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Patient Initial Assessment Report

Patient Information:

  • Name: John Doe
  • Age: 45
  • Gender: Male
  • Date of Birth: June 12, 1979
  • Contact Number: (555) 123-4567
  • Address: 123 Elm Street, Springfield, IL 62701

Referral Source:

  • Referring Physician: Dr. Jane Smith
  • Reason for Referral: Evaluation of persistent chest pain

Presenting Complaint:

  • Chief Complaint: Persistent chest pain for the past two weeks
  • Description of Pain: Dull, aching pain in the left side of the chest; occasional sharp pain radiating to the left arm

Medical History:

  • Past Medical History:
    • Hypertension (diagnosed 5 years ago)
    • Type 2 Diabetes Mellitus (diagnosed 3 years ago)
    • Hyperlipidemia
  • Surgical History:
    • Appendectomy (2005)
  • Allergies:
    • No known drug allergies
  • Medications:
    • Lisinopril 20 mg daily
    • Metformin 500 mg twice daily
    • Atorvastatin 10 mg daily

Family History:

  • Father: Deceased (age 65) - Myocardial infarction
  • Mother: Age 70 - Hypertension, Type 2 Diabetes Mellitus

Social History:

  • Occupation: Office Manager
  • Smoking: 1 pack per day for 20 years, quit 2 years ago
  • Alcohol Use: Social drinker, 1-2 drinks per week
  • Exercise: Sedentary lifestyle

Review of Systems:

  • Cardiovascular: Chest pain, occasional palpitations
  • Respiratory: No shortness of breath or cough
  • Gastrointestinal: No nausea, vomiting, or changes in bowel habits
  • Genitourinary: No dysuria or hematuria
  • Neurological: No headaches, dizziness, or syncope

Physical Examination:

  • Vital Signs:
    • Blood Pressure: 140/85 mmHg
    • Heart Rate: 88 beats per minute
    • Respiratory Rate: 16 breaths per minute
    • Temperature: 98.6°F (37°C)
  • General Appearance: Alert, well-nourished male in no acute distress
  • Cardiovascular Exam: Normal heart sounds, no murmurs or gallops, regular rhythm
  • Respiratory Exam: Clear breath sounds bilaterally, no wheezing or rales
  • Abdominal Exam: Soft, non-tender, no hepatosplenomegaly
  • Musculoskeletal Exam: Full range of motion, no joint swelling or tenderness

Initial Diagnostic Plan:

  • Laboratory Tests:
    • Complete Blood Count (CBC)
    • Comprehensive Metabolic Panel (CMP)
    • Lipid Profile
    • Cardiac Biomarkers (Troponin I, BNP)
  • Imaging:
    • Electrocardiogram (ECG)
    • Chest X-ray

Assessment and Plan:

  • Assessment:
    • Persistent chest pain with a history of hypertension, diabetes, and hyperlipidemia raises concerns for potential cardiovascular disease.
  • Plan:
    • Continue current medications.
    • Order necessary diagnostic tests to evaluate for cardiac causes of chest pain.
    • Refer for cardiology consultation if tests are abnormal.
    • Schedule follow-up appointment in 1 week to review test results and discuss further management.

Provider’s Name: Dr. Emily Johnson Date: September 9, 2024

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