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Medical Examination Report

Medical Examination Report

[Your Company Name]

[Your Company Email]

123 Wellness Lane Springfield, IL 62701

Patient Information

  • Name: [Patient's Name]

  • Date of Birth: [Patient's Birthdate]

  • Gender: Male

  • Address: [Patient's Address]

  • Phone Number: [Patient's Contact Number]

  • Email: [Patient's Email]

Examination Details

  • Date of Examination: October 1, 2024

  • Referring Physician: Dr. Jane Smith

  • Reason for Examination: Annual physical examination and routine health check-up

Medical History

  • Allergies: None

  • Current Medications: Lisinopril 10 mg daily for hypertension

  • Past Medical History: Hypertension diagnosed in 2015, well-controlled; no surgeries

  • Family History: Father with coronary artery disease; mother with type 2 diabetes

Physical Examination Findings

  • Vital Signs:

    • Blood Pressure: 120/80 mmHg

    • Heart Rate: 72 bpm

    • Respiratory Rate: 16 breaths/min

    • Temperature: 98.6°F

    • Height: 5 ft 10 in

    • Weight: 180 lbs

  • General Appearance: Patient appears healthy and well-nourished, in no acute distress.

  • Head and Neck Examination: No abnormalities noted; throat clear, no lymphadenopathy.

  • Cardiovascular Examination: Heart sounds normal; no murmurs or gallops. Peripheral pulses intact.

  • Respiratory Examination: Clear lung fields bilaterally; no wheezing or crackles.

  • Abdominal Examination: Soft, non-tender, no organomegaly, bowel sounds normal.

  • Neurological Examination: Alert and oriented; cranial nerves intact, normal reflexes.

  • Musculoskeletal Examination: Full range of motion, no swelling or tenderness.

Laboratory and Diagnostic Tests

  • Blood Tests:

    • Complete Blood Count: Normal

    • Lipid Panel: Total Cholesterol 180 mg/dL, LDL 100 mg/dL, HDL 60 mg/dL

    • Glucose: 90 mg/dL

  • Urinalysis: Normal; no signs of infection or protein.

  • Imaging Studies: Chest X-ray: Clear lungs, no acute abnormalities.

Assessment

  • Summary of Findings: Overall healthy with well-controlled hypertension; no acute issues noted during the examination.

  • Diagnosis: Essential hypertension, controlled; no additional medical conditions identified.

Recommendations

  • Continue current medication (Lisinopril) and monitor blood pressure regularly.

  • Maintain a balanced diet and regular exercise regimen to manage weight.

  • Schedule follow-up in one year for the next annual examination or sooner if symptoms develop.

  • Recommend a consultation with a nutritionist for dietary guidance.

Physician's Signature:

[Your Name]
Medical License Number: IL123456
October 2, 2068

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