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
Lisinopril
10mgMetformin
500mgFollow-up 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
Name
Dr. Robert Chen
Specialty
Internal Medicine
Qualifications
MD, FACP
robert.chen@hospital.com
Phone
+1 (555) 987-6543
Comprehensive Physical Examination
A thorough physical examination including vital signs, body systems review, and health assessment
Ultrasound of Abdomen
Imaging of abdominal organs including liver, kidneys, and gallbladder
Basic Metabolic Panel
Blood test measuring glucose, calcium, electrolytes, and kidney function
Spirometry
Lung function test to measure breathing capacity
Wound Care
Treatment of minor wounds including cleaning, dressing, and bandaging