Doctor’s Medical Report
I. Patient Information
Patient Name: | [Your Name] |
Patient ID: | 123456789 |
Date of Birth: | January 1, 2050 |
Gender: | Male |
Contact Information: | 123-456-7890 |
Chief Complaint
The patient has come in for an evaluation, reporting an ongoing experience of chest pain. The discomfort started around two weeks before the current visit and has been persistent since that time.
History of Present Illness
[Your Name] is a 45-year-old male who reports experiencing intermittent chest pain radiating to the left arm, particularly during physical exertion. The pain is described as a pressure sensation, lasting approximately 15 minutes at a time. The patient denies shortness of breath or nausea. He has a family history of heart disease, with his father having a myocardial infarction at age 50.
Past Medical History
Hypertension, controlled with medication
Hyperlipidemia, managed with dietary changes
Medications:
Lisinopril 10 mg daily
Atorvastatin 20 mg daily
Allergies:
Physical Examination
Vital Signs:
General Appearance: Patient appears in no acute distress.
Cardiovascular: Regular rhythm, no murmurs or gallops.
Respiratory: Clear to auscultation bilaterally.
Abdomen: Soft, non-tender, no organomegaly.
Diagnostic Tests
ECG: Normal sinus rhythm, no acute changes noted.
Chest X-ray: Clear, no signs of cardiomegaly or pulmonary pathology.
Lab Tests:
Diagnosis
Treatment Plan
Start the patient on nitroglycerin sublingual as needed for chest pain.
Refer to a cardiologist for further evaluation, including a stress test and possible cardiac catheterization.
Recommend dietary modifications to address hyperlipidemia.
Schedule a follow-up appointment in one month to assess progress and response to treatment.
Follow-Up
Signature:
Dr. Emily White, MD
Internal Medicine
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