Free Medical Note Template
Medical Report
Prepared by: [YOUR NAME]
Patient's Information
Name: Mike Butler
Age: 45
Gender: Male
Date: January 17, 2052
Medical History
Mr. Butler has a history of hypertension diagnosed five years ago. He underwent an appendectomy in 2050. He is not allergic to any known medications. Current medications include Atenolol 50 mg once daily.
Present Illness
Mr. Smith presented with a two-week history of progressively worsening headaches, dizziness, and occasional blurred vision. Symptoms are aggravated during stressful situations.
Examination Findings
-
Vital Signs: Blood pressure 150/90 mmHg, heart rate 75 bpm, respiratory rate 16 breaths/min.
-
Neurological Exam: Cranial nerves intact, no focal deficits observed.
-
Ophthalmic Exam: Fundoscopy reveals bilateral retinal arteriolar narrowing.
-
Others: No other abnormalities were noted in cardiovascular, respiratory, or abdominal examinations.
Diagnosis
Hypertensive crisis with associated hypertensive retinopathy.
Treatment Plan
1. Medications
-
Atenolol was increased to 100 mg once daily.
-
Initiate Lisinopril 10 mg once daily.
-
Prescribe Amlodipine 5 mg once daily.
2. Therapies
-
Schedule ambulatory blood pressure monitoring.
-
Referral to an ophthalmologist for further evaluation.
3. Dietary Recommendations
-
Low-sodium diet.
-
Encourage increased intake of fruits and vegetables.
4. Lifestyle Changes
-
Stress management techniques.
-
Regular aerobic exercise.
5. Follow-Up Plans
-
Follow-up in two weeks for blood pressure reassessment.
-
Ophthalmology appointment scheduled for retinal evaluation.
