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

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

Comprehensive Physical Examination

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

$150.00
Code: 99215
Evaluation and Management

Ultrasound of Abdomen

Imaging of abdominal organs including liver, kidneys, and gallbladder

$250.00
Code: 76700
Radiology

Chest X-Ray

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

$120.00
Code: 71045
Radiology