Patient History Report

Total Care Clinic

Name Charlie Nowak Blood Pressure 140/90

Age 38 Heart Rate 60

Height 5 ft. 8 in. Respiratory 12

Rate
Weight 140 pounds

Temperature 98.7 degrees F

Sex Female

SpO2 98%

BMI 21.3

Alerts:
Has headache going on for 3 days, has been getting worse.
Has high blood pressure
Headache does not go away, scaled the pain as 7/10
BMI: 28.6 overweight
Patient Reminders:
Drink Water
Schedule annual skin ancer check
Schedule Flu shot
Get good sleep
Stay of screens

Medications:

Been taking ibuprofen to help with headache, does not work

Sproadic use of multivitamins
Appointment Notes:
-Ears, nose and throat were normal
-small amount of mucus in nasal cavities
-Heart and lung sounds were normal
Urine sample taken and sent to lab for testing (dark yellow color)
-There was a slight decrease in skin turgor upon physical exam
-A mole on the left shoulder showed irregular borders and at least 3 distinct colors
-Eye exam was normal; Visual acuity- 20/70 in right eye; 20/50 in left eye
-Does not wear corrective lens.
-Pain in temples
-Work has been very stressful

History:
-Appendectomy as a child
-hospital stay following the surgery
-High blood pressure at checkup last year but changed diet following the appointment
-Mom had migraines in 20's and 30's
-Dad has high blood pressure and high cholesterol
Grandfather had lung cancer

Health Conditions:
Headaches
Lab Results:
High RBC, 0.5 millions more than normal range
-High sodium level, 146 mmol/L
-High Chloride level, 108 mmol/L
-Urine shoed a higher than normal specific gravity
Cholesterol Panel:
Total: 198 mg/dL
LDL: 120 mg/dL , HDL: 47 mg/dL

Medical Procedures:

Appendectomy at Age 8

Imaging Results:
n/a
Plan of Care:
Eye movement test and memory test and motor strength and coordination test. Increase drinking
water to help migraines and lower hemtaocrit levels. Increase excercises to help lower LDL levels.