Medical Records

Patient Summary
Patient
John Smith
MRN-12345
45
Age
Male
Gender
O+
Blood Type
Allergies
Penicillin
Shellfish
Conditions
Diabetes Type 2
Hypertension
Provider
Dr. Sarah Wilson
Primary Care Physician
Insurance
Aetna Health Plan
Policy: AET-789456123
Recent Lab Results
Glucose
09/18/2024
145 mg/dL
70-100
Cholesterol
09/18/2024
180 mg/dL
<200
HbA1c
08/15/2024
7.2%
<7%
Medical Timeline
Annual Physical Examination
September 15, 2024 Dr. Sarah Wilson Completed
Chief Complaint: Routine annual physical examination
135/85
Blood Pressure
72
Heart Rate
98.6°F
Temperature
185 lbs
Weight
Assessment: Patient presents for routine annual examination. Overall health status is stable with well-controlled diabetes and hypertension. Blood pressure slightly elevated, medication adjustment recommended.
Plan:
  • Continue current diabetes medication regimen
  • Increase lisinopril dosage for blood pressure control
  • Follow-up appointment in 3 months
  • Lab work ordered: HbA1c, lipid panel
Laboratory Results
September 10, 2024 LabCorp Abnormal
Test Result Reference Range Status
Glucose (Fasting) 145 70-100 mg/dL High
Total Cholesterol 180 <200 mg/dL Normal
HDL Cholesterol 45 >40 mg/dL Normal
LDL Cholesterol 110 <100 mg/dL High
Prescription Update
September 5, 2024 Dr. Sarah Wilson Active
  • Lisinopril 10mg
    Once daily, morning
    30 day supply
    2 refills remaining
  • Metformin 500mg
    Twice daily with meals
    90 day supply
    5 refills remaining
Follow-up Visit - Diabetes Management
June 20, 2024 Dr. Sarah Wilson Completed
Chief Complaint: Diabetes follow-up, review of recent lab results
Assessment: Patient's diabetes management has improved with current medication regimen. HbA1c has decreased from 8.1% to 7.5%. Blood pressure remains elevated, considering medication adjustment.
Plan:
  • Continue current Metformin dosage
  • Patient education on diet and exercise reinforced
  • Schedule appointment with nutritionist
  • Return in 3 months for follow-up
Emergency Department Visit
March 10, 2024 General Hospital ED Emergency
Chief Complaint: Chest pain and shortness of breath
Assessment: Patient presented with acute chest pain. EKG and cardiac enzymes normal. Likely gastroesophageal reflux disease (GERD) exacerbation. No evidence of cardiac event.
Discharge Instructions:
  • Started on proton pump inhibitor
  • Dietary modifications recommended
  • Follow-up with primary care physician in 1 week
  • Return to ED if symptoms worsen