Medical Report: Assessment of Sarah Johnson's Medical Condition

Medical Report: Assessment of Sarah Johnson's Medical Condition  

This medical report has been prepared to evaluate Sarah Johnson's health status in support of her application for short-term disability benefits. It includes a detailed overview of her presenting symptoms, the results of relevant medical investigations, and a recommended management plan tailored to her current condition.

Steps

1. Patient Information

Name: Sarah Johnson

·         Date of Birth: January 15, 1989(35-year-old)

·         Address: [Confidential]

·         Contact Information: [Confidential]

·         Date of Report: December 11, 2024

2. Referring Physician

·         Name: Dr. Emily Carter

·         Practice Name: HEALTH LIFE Medical Center

·         Contact Information: [Confidential]

3. Purpose of ReportThis medical report has been prepared to provide an assessment of Sarah Johnson's medical condition in relation to her application for short-term disability benefits. It outlines her current health issues, the findings from recent investigations, and a proposed management plan to address her symptoms.

4. Medical HistorySarah has been experiencing recurrent headaches and fatigue over the past six months. She reports that these symptoms have gradually worsened, significantly impacting her daily functioning and work performance. Previous medical history is unremarkable for any chronic conditions, and she denies any recent major illnesses or injuries.

5. Presenting Complaints

ü  Persistent headaches, described as a tight, band-like sensation around the head, occurring daily.

ü  Chronic fatigue, particularly in the mornings, which persists throughout the day.

6. Clinical Examination Findings

·         Blood pressure: 120/80 mmHg (normal range).

·         No focal neurological deficits observed.

·         Normal eye examination with no papilledema.

·         Tenderness in the neck and shoulder muscles consistent with tension-type headaches.

7.  Investigations Conducted

·         Blood tests: Normal complete blood count (CBC), normal thyroid function tests, and no signs of anemia.

·         MRI of the brain: No abnormalities detected.

·         Sleep study: Indicative of reduced sleep quality, likely due to stress.

8. Assessment

·         The recurrent headaches are likely tension-type headaches associated with stress and muscle tension.

·         Fatigue is likely secondary to poor sleep quality and ongoing stress.

·         Blood tests indicate no significant abnormalities, ruling out anemia or thyroid dysfunction as contributors to fatigue.

·         Stress levels, as assessed through patient self-reporting, are significantly elevated, which may exacerbate both headaches and fatigue.

9. Management Plan

·         Recommend lifestyle modifications, including stress management techniques such as yoga or meditation.

·         Encourage regular physical activity, such as walking or swimming, for at least 30 minutes, five times a week.

·         Prescribe over-the-counter analgesics, such as acetaminophen or ibuprofen, for headache relief as needed.

·         Suggest a consultation with a mental health professional if stress persists.

·         Schedule a follow-up appointment in one month to reassess symptoms and evaluate the effectiveness of the management plan.

10. Conclusion
Sarah Johnson’s symptoms of headaches and fatigue appear to be linked to stress and muscle tension rather than an underlying medical disorder. The proposed management plan aims to address her symptoms and improve her quality of life. Continued monitoring and follow-up will be necessary to evaluate her response to treatment.

11. Signature
                                                                                                        Dr. Emily Carter
                                                                                                      Health life Center

Activity 2:Essay vs Rapport Analysis

·         Part I :

Filling the Comparison Table

·         Part II :

The difference between an essay

1.      Purpose:

·         Essay: Focuses on arguing a position, analyzing a topic, or responding to an issue, often expressing a subjective viewpoint.

·         Report: Provides objective information and analysis, often with recommendations or actions based on findings.

2.      Structure :

·         Essay: Typically follows a continuous narrative format with an introduction, body, and conclusion.

·         Report: Has a formal structure, including sections such as a title page, table of contents, executive summary, and headings for clear organization.

3.      Use of Data :

·         Essay: May use references or sources to support arguments but generally avoids detailed data tables or figures.

·         Report: Frequently incorporates data, figures, tables, and charts to support its objective findings and recommendations.