[Medical Report]
Patient Information:
Name: John Doe
Age: 45
Gender: Male
Date of Birth: [Date of Birth]
Date of Admission: [Date of Admission]
Date of Discharge: [Date of Discharge]
Medical Record Number: [Medical Record Number]
Address: [Patient's Address]
Phone Number: [Patient's Phone Number]
Chief Complaint:
The patient presented with complaints of persistent chest pain and shortness of
breath for the past week.
History of Present Illness:
Mr. John Doe reported that he began experiencing intermittent chest pain
approximately one week ago. The pain was described as a tight, squeezing sensation,
radiating to the left arm. It was aggravated by physical exertion and relieved by rest.
He also noted increased shortness of breath during these episodes. The patient denies
any history of similar symptoms in the past. He sought medical attention due to the
persistence and severity of his symptoms.
Past Medical History:
Hypertension (diagnosed 5 years ago)
Hyperlipidemia
No history of diabetes or other chronic illnesses
No history of cardiovascular diseases
Family History:
Father - Deceased (Myocardial Infarction at age 58)
Mother - Alive, Hypertension
Siblings - No known cardiovascular diseases
Social History:
Mr. Doe is a non-smoker and reports occasional alcohol consumption
(approximately 2 drinks per week). He works as an office manager and does not
engage in regular physical exercise.
Physical Examination:
General: The patient appears in mild distress, with moderate respiratory effort.
Vital Signs: Blood pressure 140/90 mmHg, heart rate 88 bpm, respiratory rate 20
breaths per minute, temperature 37.2°C (oral).
Cardiovascular: Regular rhythm, normal S1 and S2 heart sounds, no murmurs or
extra sounds.
Respiratory: Mild inspiratory crackles in the lower lung fields.
Abdomen: Soft, non-tender, and non-distended.
Neurological: Cranial nerves intact, no focal deficits noted.
Diagnostic Findings:
Electrocardiogram (ECG): Sinus rhythm, no ST-segment elevation or significant
abnormalities.
Chest X-ray: Mild pulmonary congestion, no signs of acute pathology.
Cardiac Enzymes: Troponin I levels elevated (0.12 ng/mL, normal range < 0.03
ng/mL).
Lipid Profile: Total cholesterol and LDL levels elevated.
Echocardiogram: Left ventricular hypertrophy, ejection fraction of 55%.
Assessment:
Based on the patient's clinical presentation and diagnostic findings, Mr. John Doe is
diagnosed with unstable angina. The elevated troponin levels and evidence of left
ventricular hypertrophy on echocardiogram suggest an increased risk of
cardiovascular events.
Plan:
The patient will be closely monitored in the hospital to assess cardiac function and
manage his symptoms.
Nitroglycerin and aspirin will be administered to relieve chest pain and reduce the
risk of clot formation.
Statin therapy will be initiated to manage hyperlipidemia and reduce cardiovascular
risk.
Lifestyle modifications, including dietary changes and regular exercise, will be
recommended to improve overall cardiovascular health.
The patient will receive education regarding the signs and symptoms of angina and
the importance of seeking immediate medical attention in case of exacerbation.
Follow-up:
Mr. Doe will be advised to follow up with his primary care physician regularly for
ongoing monitoring and management of his cardiovascular risk factors.
Conclusion:
Mr. John Doe presents with unstable angina, requiring immediate medical
intervention and close monitoring. The patient's cooperation in adhering to
prescribed medications and lifestyle changes is crucial for the management of his
condition and to reduce the risk of cardiovascular complications.
[Signature of the Physician]
[Physician's Name, Credentials]
[Date of the Medical Report]