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, osteoarthritis
  • Siblings: One younger brother with no significant health issues

Social History:

  • Occupation: Teacher
  • Smoking: Non-smoker
  • Alcohol Use: Occasionally, 1-2 drinks per month
  • Exercise: Regular exercise, jogging 3 times a week

Review of Systems:

  • Neurological: Severe, unilateral headaches with associated dizziness; occasional blurred vision
  • Respiratory: No shortness of breath or wheezing
  • Gastrointestinal: No abdominal pain, nausea, or changes in appetite
  • Musculoskeletal: No joint pain or muscle weakness

Physical Examination:

  • Vital Signs:
    • Blood Pressure: 120/75 mmHg
    • Heart Rate: 78 beats per minute
    • Respiratory Rate: 14 breaths per minute
    • Temperature: 98.4°F (36.9°C)
  • General Appearance: Alert and oriented, appearing uncomfortable due to headache
  • Neurological Exam: No focal deficits; normal gait; slight sensitivity to light on examination
  • Respiratory Exam: Clear breath sounds bilaterally
  • Cardiovascular Exam: Normal heart sounds, no murmurs
  • Abdominal Exam: Soft and non-tender; no abnormalities noted

Initial Diagnostic Plan:

  • Laboratory Tests:
    • Complete Blood Count (CBC)
    • Comprehensive Metabolic Panel (CMP)
  • Imaging:
    • MRI of the Brain (to evaluate for structural abnormalities)
    • Consider referral to a neurologist for further evaluation if initial tests are inconclusive

Assessment and Plan:

  • Assessment:
    • Migraine headaches with recent worsening symptoms, possibly contributing to dizziness.
  • Plan:
    • Prescribe a triptan medication for migraine management.
    • Advise on lifestyle modifications and headache triggers.
    • Recommend keeping a headache diary to identify patterns or triggers.
    • Schedule follow-up appointment in 2 weeks to review response to medication and further management.
    • Educate the patient on the importance of follow-up and seeking medical attention if symptoms worsen or new symptoms arise.

Provider’s Name: Dr. Laura Mitchell Date: September 9, 2024

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