Patient History Report

Total Care Clinic

Name Charlie Nowak Blood Pressure 140/90 mm Hg

Age 38 Heart Rate 60 bpm

Height 5'8" Respiratory 12 bpm

Rate
Weight 140

Temperature 98.7 F
Sex Female

SpO2 98%

BMI 21.28

Alerts:
No known food or drug allergies

Patient Reminders:
Schedule your flu shot Schedule annual skin cancer check

Medications:
Ibuprofen (as needed for pain) Multivitamin (sporadic use)
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 the lab for testing. Urine was 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 three distinct colors. Eye exam was normal; Visual acuity -
20/70 in right eye; 20/50 in left eye. Patient does not wear corrective lens. Hypertension Stage 2.

History:
Charlie was here for her annual checkup. She reported having headpain which has been going of
for more than 3 days. Lights also make it worse. She reported the pain being really bad, and a
7/10. She has less pain in the morning and more when she excercises, but it mainly stays
constant. She also had nausea and vomiting. Patient says she is highly stressed at work too. She
has history of migraines, high blood pressure/cholesterol, and lung cancer. She doesn't smoke or
drink alcohol. She is married but no kids, and she went to Minnesota for a trip recently. She drinks
coffee but not alot of water. Takes no alcohol or smoking. Surgery for appendicitis as a kid. Her
mom had migraines in her 20s and 30s, and her dad had elevated cholesterol and blood pressure
levels. Her grandpa had lung cancer. She recently went to a trip to Minnesota. She used to havee
high blood pressure last year, but she made an alter to her diet. Patient had taken ibuprofen
beforehand, and Mulltivitamins occasionally.

Health Conditions:
Elevated Blood Pressure last year. No other health conditions.
Lab Results:
Sodium levels are 146 mmol/L when normal range should be 134 – 144 mmol/L. Potassium is 5.2
mmol/L but should be 3.5 – 5.2 mmol/L. Her HDL is too low as it is 47 but optimal levels are 60.
Her LDL is 1200 which is near optimal. Urine showed a higher than normal specific gravity. RBC
count elevated. Hematocrit levels are elevated.

Medical Procedures:
Appendectomy at age 8.

Imaging Results:
No recent imaging results.
Plan of Care:
Refer to a Darmatologist to take care of mole and skin turgor. She should also see a optometrist
to correct her vision. She needs to drink more water, preferably in a water bottle so she can see
how much to drink in a day. She should avoid drinking too much coffee as it dehydrates. She
should start eating a balanced diet, and should see a dietitian for more info. Should eat
unsaturated fats like olive oil and avocado oil instead of saturated fats like eggs, butter, and
meats. To regain lost electrolytes, she should drink water, Gatorade, and prime.