Patient Info

Name

Sarah Johnson

Date of Birth

8/21/1992

Gender

Female

Contact

sarah.johnson@email.com

+1 (555) 234-5678

History

3 consultations

Last visit: 2/15/2024

Current Medications

Levothyroxine

50mcg

Frequency: Once daily

Started: 11/1/2022

Cancelled

Follow-up Consultation

Monday, March 18, 2024 at 9:00 AM

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

Basic Metabolic Panel

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

$75.00

Code: 80048

Laboratory

Influenza Vaccine

Annual flu shot to prevent seasonal influenza

$45.00

Code: 90688

Immunization

Comprehensive Physical Examination

A thorough physical examination including vital signs, body systems review, and health assessment

$150.00

Code: 99215

Evaluation and Management

EKG

Electrocardiogram to record electrical activity of the heart

$95.00

Code: 93010

Cardiology

Wound Care

Treatment of minor wounds including cleaning, dressing, and bandaging

$85.00

Code: 12002

Wound Care