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

EKG

Electrocardiogram to record electrical activity of the heart

$95.00

Code: 93010

Cardiology

Ultrasound of Abdomen

Imaging of abdominal organs including liver, kidneys, and gallbladder

$250.00

Code: 76700

Radiology

Influenza Vaccine

Annual flu shot to prevent seasonal influenza

$45.00

Code: 90688

Immunization

Spirometry

Lung function test to measure breathing capacity

$110.00

Code: 94010

Pulmonology