MEDICAL SUMMARY REPORT

Prepared by: [Your Name], RN

I. Patient Information

Name	John Doe
Age	58 years
Gender	Male
Address	123 Main St, Cityville, USA
Phone	(123) 456-7890

II. Medical History

Condition/Event	Details
Hypertension	Diagnosed in 2065; managed with medication
Type 2 Diabetes	Diagnosed in 2068; controlled with diet
Appendectomy	Appendectomy performed in 2055 due to acute appendicitis

III. Current Diagnosis

Condition	Details
Chronic Back Pain	Persistent lower back pain worsened in 2070

IV. Medication History

Medication	Dosage	Frequency
Lisinopril	10 mg	Once daily
Metformin	1000 mg	Twice daily
Ibuprofen	400 mg	As needed for pain

V. Treatment Plan

Treatment	Details
Physical Therapy	Sessions twice a week to manage back pain and improve mobility
Referral to Orthopedist	Scheduled for evaluation and consultation regarding surgical options for chronic back pain

VI. Laboratory and Test Results

Test/Result	Details
MRI Lumbar Spine	Showed disc herniation at L4-L5 level, causing nerve compression
Blood Glucose	Fasting glucose level: 120 mg/dL; within the target range

VII. Recommendations

A. Follow-Up Plan

Please arrange for a follow-up appointment to take place in three months. During this appointment, we will re-evaluate your back pain and make any necessary adjustments to your treatment plan.

B. Lifestyle Modifications

Encouraging individuals to engage in regular physical activities such as taking daily walks and performing stretching exercises can significantly enhance their overall health. Furthermore, it is equally important to promote adherence to a diabetic-friendly diet, which includes consuming foods that are low in carbohydrates and high in fiber. By integrating these practices into their daily routines, individuals can effectively manage and improve chronic health conditions.

C. Surgical Consultation

You should schedule a comprehensive discussion with the orthopedist to thoroughly review and evaluate all possible surgical options. During this consultation, it would be beneficial to consider specific procedures, such as a minimally invasive discectomy, which have the potential to alleviate pain and significantly improve the patient's overall quality of life.

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