Doctor%E2%80%99s Medical Report

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:

  • No known drug allergies

Physical Examination

  • Vital Signs:

    • Blood Pressure: 130/80 mmHg

    • Heart Rate: 76 bpm

    • Respiratory Rate: 18 breaths/min

    • Temperature: 98.6°F

  • 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:

    • Lipid Panel: LDL elevated at 130 mg/dL

    • Troponin: Negative

Diagnosis

  • Stable angina that occurs as a result of coronary artery disease (CAD).

Treatment Plan

  1. Start the patient on nitroglycerin sublingual as needed for chest pain.

  2. Refer to a cardiologist for further evaluation, including a stress test and possible cardiac catheterization.

  3. Recommend dietary modifications to address hyperlipidemia.

  4. Schedule a follow-up appointment in one month to assess progress and response to treatment.

Follow-Up

  • The patient is strongly advised to schedule an appointment and return to the healthcare facility at the earliest opportunity if there is any noticeable worsening of their existing symptoms or if any new health concerns or symptoms arise. This is to ensure timely medical attention and to address any potential complications promptly.

Signature:

Dr. Emily White, MD
Internal Medicine

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