Dr. Johnson
DOB: March 15, 1985 • Age: 39 • MRN: MR-2024-7891
Dr. Sarah Johnson • Internal Medicine
Chief Complaint: Routine annual checkup
Assessment: Overall good health, blood pressure slightly elevated
Plan: Continue current medications, follow-up in 3 months for BP monitoring
Dr. Sarah Johnson • Internal Medicine
Chief Complaint: Blood pressure monitoring
Assessment: BP well controlled on current medication
Plan: Continue Lisinopril 10mg daily
Dr. Michael Chen • Emergency Medicine
Chief Complaint: Chest pain and shortness of breath
Assessment: Anxiety-related chest pain, ruled out cardiac causes
Plan: Discharged home with anxiety management resources
10mg daily
April 15, 2025
Dr. Johnson
Hypertension
500mg twice daily
January 20, 2025
Dr. Johnson
Type 2 Diabetes
| Test | Result | Reference Range | Date | Status |
|---|---|---|---|---|
| Hemoglobin A1C | 6.8% | < 7.0% | July 20, 2025 | Normal |
| Total Cholesterol | 195 mg/dL | < 200 mg/dL | July 20, 2025 | Normal |
| Blood Pressure | 142/88 mmHg | < 130/80 mmHg | July 20, 2025 | Elevated |
BP Monitoring
Elevated BP reading requires follow-up
Diabetes Control
A1C within target range
Penicillin
Severe - Anaphylaxis
Shellfish
Moderate - Hives