Healthcare Record

A. Patient Information

• Full Name: Jeremy Marvin

• Date of Birth: 01/15/2050

• Gender: Male

• Address: Omaha, NE 68101

• Phone Number: 222 555 7777

• Email: jeremy@you.mail

• Insurance Provider: FutureCare Health Insurance

• Policy Number: FC-987654321

B. Visit Information

• Date of Visit: 03/01/2080

• Time of Visit: 10:30 AM

• Reason for Visit: Annual check-up and persistent fatigue

• Provider Name: Dr. Emily Carter

• Provider Specialty: Primary Care Physician

C. Medical History

Allergies:

• Penicillin: Rash and itching

Chronic Conditions:

• Hypertension: Diagnosed 01/10/2075

Surgeries:

• Appendectomy: 03/22/2060

Medications:

• Lisinopril: 20 mg once daily

D. Vital Signs

Vital Sign	Measurement	Normal Range
Blood Pressure	140/90 mmHg	<120/80 mmHg
Heart Rate	82 bpm	60-100 bpm
Respiratory Rate	18 breaths/min	12-20 breaths/min
Temperature	98.6°F	97-99°F
Weight	190 lbs	Varies by individual
Height	5'10"	—
BMI	27.3	18.5-24.9

E. Assessment

Diagnosis: Hypertension (ICD-10: I10), Fatigue (ICD-10: R53.83)

Findings: Elevated blood pressure and borderline overweight BMI. Patient reports consistent fatigue over the last three months. No signs of infection or acute illness.

Tests Ordered:

• Comprehensive Metabolic Panel (CMP)

• Thyroid Function Test (TFT)

F. Treatment Plan

1. Medications Prescribed:

   • Continue Lisinopril: 20 mg once daily

   • Vitamin D supplement: 1000 IU daily

2. Follow-Up Visits:

   • Date: 03/30/2080

   • Purpose: Review test results and assess fatigue

3. Lifestyle Recommendations:

   • Adopt a Mediterranean-style diet

   • Incorporate at least 30 minutes of moderate exercise 5 days a week

4. Referrals:

   • Endocrinologist: Dr. Sarah Lin for potential thyroid evaluation

G. Notes and Additional Information

Patient expresses concern about managing stress due to work. Counseling for stress management is recommended if symptoms persist.

Prepared By: [YOUR NAME], Medical Records Specialist
Date of Preparation: 03/01/2080

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