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:
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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