MEDICAL CONSULTATION REPORT

Patient Name: Marcus Johnson
Date of Birth: 58 years old
Gender: Male
Date of Consultation: October 20, 2025
Consultation Type: Follow-up Visit
Attending Physician: Dr. Chen

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CHIEF COMPLAINT:
Intermittent chest tightness on exertion, resolved with rest

HISTORY OF PRESENT ILLNESS:
Marcus Johnson is a 58-year-old male with a known history of Coronary Artery Disease presenting with intermittent chest tightness on exertion, resolved with rest. Symptoms have been progressive over recent days and require timely evaluation.

PAST MEDICAL HISTORY:
CAD with PCI (2022), Type 2 Diabetes, Hyperlipidemia

CURRENT MEDICATIONS:
1. Aspirin 75mg
2. Clopidogrel 75mg
3. Atorvastatin 40mg
4. Metoprolol 50mg BD

CLINICAL FINDINGS:
Vital Signs: BP 138/82 mmHg, HR 68 bpm, Temp 36.8°C, SpO2 96%

General: Patient appears in mild distress

Relevant examination findings consistent with Coronary Artery Disease

ASSESSMENT:
Coronary Artery Disease

Clinical Impression: Based on the presenting symptoms, clinical examination, and patient's medical history, the assessment is consistent with Coronary Artery Disease. Close monitoring and timely follow-up are recommended.

PLAN:
1. Continue current medications as prescribed
2. Referral to Cardiology for specialist evaluation
3. Patient education provided regarding condition management
4. Lifestyle modifications discussed as appropriate

INVESTIGATIONS RECOMMENDED:
1. Exercise Stress Test
2. Lipid Profile
3. HbA1c

FOLLOW-UP:
Follow-up appointment in 1-2 weeks to reassess

DISPOSITION:
Patient discharged with clear instructions and follow-up plan. Advised to return if symptoms deteriorate.

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Electronically signed by: Dr. Chen
Generated with MediFlow AI - Clinical Documentation Assistant
Date: October 20, 2025

This report was generated with AI assistance and reviewed by the attending physician.