Medical Summary Report
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.
