Medical Record Review

Patient Information

• Name: Malvina Jones

• Date of Birth: July 15, 2050

• Gender: Female

• Medical Record Number: 123456789

• Address: Fremont, CA 94536

• Phone Number: 222 555 7777

• Emergency Contact: Jack Jones, 222 555 7777

Review Date

• Date of Review: December 3, 2088

Reason for Review

Annual Check-up and Evaluation of Chronic Conditions

Patient History

Medical History:

• Hypertension (Diagnosed in 2070)

• Type 2 Diabetes (Diagnosed in 2075)

• Hyperlipidemia (Diagnosed in 2077)

• No known drug allergies

• Family History: Mother with a history of cardiovascular disease, Father with Type 2 diabetes.

Surgical History:

• Appendectomy (2060)

• Knee Arthroscopy (2070)

Social History:

• Non-smoker, occasional alcohol use

• Sedentary lifestyle, primarily desk work

Clinical Findings

Vital Signs:

Measurement	Value	Unit	Date of Measurement
Blood Pressure	140/90	mmHg	December 3, 2088
Heart Rate	80	bpm	December 3, 2088
Respiratory Rate	16	bpm	December 3, 2088
Temperature	37.0	°C	December 3, 2088
Oxygen Saturation	98	%	December 3, 2088

Physical Examination:

• General Appearance: Well-nourished, alert, and oriented.

• Cardiovascular: Regular rhythm, no murmurs.

• Respiratory: Clear to auscultation bilaterally.

• Abdomen: Soft, non-tender, no organomegaly.

• Extremities: No cyanosis or edema.

Laboratory Results:

• Hemoglobin A1c: 7.2% (Elevated)

• Cholesterol: Total 220 mg/dL, LDL 140 mg/dL, HDL 45 mg/dL (Elevated LDL)

• Kidney Function (Creatinine): 1.2 mg/dL (Normal)

• Liver Function Tests: Within normal limits

Imaging Results:

• Chest X-ray: Clear, no signs of congestion or mass.

• Abdominal Ultrasound: No abnormalities noted, liver and kidneys appear normal.

Diagnosis

• Primary Diagnosis: Hypertension (Uncontrolled)

• Secondary Diagnoses:

  • Type 2 Diabetes (Controlled)

  • Hyperlipidemia (Uncontrolled)

Treatment Plan

Medications:

• Lisinopril 10 mg daily (For Hypertension)

• Metformin 500 mg twice daily (For Diabetes)

• Atorvastatin 20 mg nightly (For Hyperlipidemia)

Procedures:

• Follow-up Blood Pressure Check: Every 2 weeks

• Diet and Exercise Consultation: Referral to nutritionist for diabetic and hypertension management.

Referrals:

• Cardiologist: For further evaluation of hypertension and cardiovascular risk

• Endocrinologist: For diabetic management and medication review

Follow-Up Care:

• Next Check-Up Appointment: January 15, 2089 for routine follow-up and lab work review.

• Lifestyle Modifications: Encouraged to begin a low-sodium diet and increase physical activity to 30 minutes daily.

Comments/Recommendations

• Patient is encouraged to monitor blood pressure at home and maintain a healthy diet with reduced salt intake.

• Consider adjusting medications if blood pressure remains above goal after 1 month.

Review Summary

• Reviewed by: [YOUR NAME]

• Reviewed for: [YOUR COMPANY NAME]

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