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
500mgEmergency 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. Maria Rodriguez
Specialty
Emergency Medicine
Qualifications
MD, FACEP
maria.rodriguez@hospital.com
Phone
+1 (555) 876-5432
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
Spirometry
Lung function test to measure breathing capacity
Chest X-Ray
Radiographic examination of the chest to evaluate heart, lungs, and other structures