Doctor Progress Note Format

Date: September 12, 2095

Patient Name: Edgar Spencer

DOB: March 15, 2050

Patient ID: 54321

Visit Date: September 10, 2095

Provider: Dr. [Your Name]

Specialty: Internal Medicine

Facility: [Your Company Name]

Contact: [Your Company Email] | [Your Company Number]

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Reason for Visit:

Follow-up evaluation for chronic hypertension.

Clinical Findings:

• Blood Pressure: 142/90 mmHg

• Heart Rate: 76 bpm, regular

• Symptoms Reported: Frequent headaches, occasional dizziness, mild fatigue

Current Medications:

• Lisinopril 20 mg daily

• Hydrochlorothiazide 25 mg daily

Assessment:

Edgar has demonstrated some improvement in blood pressure control since the last visit; however, his hypertension remains inadequately managed. His current blood pressure readings indicate persistent issues, and he continues to experience frequent headaches and mild dizziness, which may be attributed to either his elevated blood pressure or possible medication side effects.

Plan:

1. Adjust Medication:

   • Increase Lisinopril dosage to 40 mg daily.

   • Continue Hydrochlorothiazide at 25 mg daily.

2. Lifestyle Recommendations:

   • Advise reduced sodium intake and promote regular physical activity, aiming for at least 150 minutes of moderate exercise weekly.

   • Suggest maintaining a food diary to track dietary habits.

3. Follow-Up:

   • Schedule next appointment for October 15, 2095, to reassess blood pressure and evaluate the effectiveness of the medication adjustment.

4. Additional Testing:

   • Order a 24-hour ambulatory blood pressure monitoring to obtain a more comprehensive understanding of his blood pressure variations throughout the day.

5. Patient Education:

   • Edgar was informed about the critical role of medication adherence and the need for lifestyle changes to effectively manage his hypertension. He was instructed to monitor his blood pressure at home regularly and to report any significant changes or new symptoms, such as increased frequency of headaches or any signs of lightheadedness.

Notes:

Edgar has been advised to avoid strenuous activities that might worsen his symptoms. He should seek immediate medical attention if he experiences severe headaches, persistent dizziness, or any other concerning symptoms. Regular check-ins and adherence to the treatment plan are crucial for his health moving forward.

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