Patient Info

Name

John Smith

Date of Birth

3/15/1980

Gender

Male

Contact

john.smith@email.com

+1 (555) 123-4567

History

5 consultations

Last visit: 3/1/2024

Current Medications

Lisinopril

10mg
Frequency: Once daily
Started: 1/15/2023

Metformin

500mg
Frequency: Twice daily
Started: 2/1/2023
Scheduled

Initial Consultation

Insights

Current Medication

Patient is on Lisinopril which may cause dizziness as a side effect

Stress Factors

Recent work-related stress reported, potentially contributing to symptoms

Sleep Pattern

Irregular sleep schedule noted - averaging 5-6 hours per night

Symptoms

Persistent headache

Frontal area pain

Throbbing sensation

Worse in morning

Diagnosis

Tension headache - Primary diagnosis

Possible migraine - Secondary consideration

Recommendations

Prescription-strength pain relief

Keep headache diary

Stress management techniques

Follow-up

Schedule follow-up in 2 weeks if symptoms persist

Attending Doctor

Name

Dr. Robert Chen

Specialty

Internal Medicine

Qualifications

MD, FACP

Email

robert.chen@hospital.com

Phone

+1 (555) 987-6543

Relevant Procedures

EKG

Electrocardiogram to record electrical activity of the heart

$95.00
Code: 93010
Cardiology

Spirometry

Lung function test to measure breathing capacity

$110.00
Code: 94010
Pulmonology

Chest X-Ray

Radiographic examination of the chest to evaluate heart, lungs, and other structures

$120.00
Code: 71045
Radiology

Basic Metabolic Panel

Blood test measuring glucose, calcium, electrolytes, and kidney function

$75.00
Code: 80048
Laboratory