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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Patient's Initial Assessment Report: Example 2

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Patient Initial Assessment Report Patient Information: Name: Maria Gonzalez Age: 38 Gender: Female Date of Birth: October 22, 1985 Contact Number: (555) 987-6543 Address: 456 Oak Avenue, Lincoln, NE 68508 Referral Source: Referring Physician: Dr. Robert Lee Reason for Referral: Evaluation of recurring headaches and dizziness Presenting Complaint: Chief Complaint: Severe headaches and episodes of dizziness occurring over the past month Description of Headaches: Throbbing pain primarily on the right side of the head, associated with nausea and sensitivity to light Medical History: Past Medical History: Migraine headaches (diagnosed 5 years ago) Asthma (diagnosed in childhood, well-controlled) Surgical History: No significant surgical history Allergies: Penicillin (rash) Medications: Ibuprofen 400 mg as needed for headaches Albuterol inhaler as needed for asthma Family History: Father: Age 65 - Hypertension, history of stroke Mother: Age 63 - Type 2 Diabetes Mellitus, osteoarthr
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Medical Report: Progress Note 1

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Patient Name: Emily Carter Date: September 9, 2024 Provider: Dr. Michael Lewis Visit Type: Follow-up Chief Complaint: Follow-up for management of asthma and recent exacerbation. Subjective: Patient reports improvement in asthma symptoms since starting new inhaler. However, occasional wheezing at night persists. Objective: Vital Signs: Blood Pressure: 118/76 mmHg Heart Rate: 80 bpm Respiratory Rate: 16 bpm Temperature: 98.2°F (36.8°C) Respiratory Exam: Breath sounds clear bilaterally, occasional wheezing noted in the right lower lung field. Medication Adherence: Adheres to new inhaler regimen but reports occasional missed doses. Assessment: Asthma symptoms partially controlled with current medication. Persistent nocturnal wheezing may indicate suboptimal control. Plan: Continue current inhaler therapy. Increase the frequency of the use of the inhaled corticosteroid. Educate patient on proper inhaler technique and the importance of regular use. Schedule follow-up appointment in 4 wee
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Medical Report: Patient History and Physical Report (H&P)

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  Patient Name: Robert Jenkins Date: September 9, 2024 Provider: Dr. Laura Mitchell Chief Complaint: New onset of abdominal pain. History of Present Illness: 48-year-old male presenting with severe abdominal pain for the past 3 days. Pain is diffuse, with occasional sharp episodes. No recent changes in bowel habits. Past Medical History: History of gastritis No prior surgeries Medications: Omeprazole 20 mg daily Family History: Father: Deceased (age 70) - History of colon cancer Mother: Age 72 - Hypertension Social History: Occupation: Construction worker No smoking Drinks alcohol occasionally Review of Systems: Gastrointestinal: Severe abdominal pain, nausea Cardiovascular: No chest pain or palpitations Respiratory: No shortness of breath or cough Physical Examination: Vital Signs: Blood Pressure: 130/85 mmHg Heart Rate: 76 bpm Respiratory Rate: 18 bpm Temperature: 98.6°F (37°C) Abdominal Exam: Tenderness in the lower abdomen, no rebound tenderness, normal bowel sounds Assessmen
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