Electronic Health Record

Patient Information

Name	Jane Doe	Date of Birth	15 May 1985
Patient ID	JD198505	Gender	Female
Blood Type	O+	Allergies	Penicillin, Peanuts

Vital Signs (Last Recorded: 10 August 2024)

Blood Pressure	138/88 mmHg	Heart Rate	72 bpm
Respiratory Rate	16 breaths/min	Temperature	37.2°C (98.9°F)
Height	165 cm (5'5")	Weight	68 kg (150 lbs)
BMI	25.0	Oxygen Saturation	98%

Medical History

Type 2 Diabetes Mellitus (diagnosed 2018)
Hypertension (diagnosed 2020)
Hyperlipidemia (diagnosed 2019)
Appendectomy (2005)
Recurrent migraines (onset 2010)

Family History

Father: Type 2 Diabetes, Myocardial Infarction at age 62
Mother: Breast Cancer at age 55, Hypertension
Maternal Grandmother: Alzheimer's Disease
Paternal Grandfather: Stroke at age 70

Current Medications

Medication	Dosage	Frequency	Start Date
Metformin	1000 mg	Twice daily	15 June 2018
Lisinopril	10 mg	Once daily	3 March 2020
Atorvastatin	20 mg	Once daily at bedtime	22 September 2019
Sumatriptan	50 mg	As needed for migraines	7 April 2010

Laboratory Results

Blood Test (5 August 2024)

Test	Result	Reference Range
Hemoglobin A1c	7.2%	<5.7%
Fasting Blood Glucose	132 mg/dL	70-99 mg/dL
Total Cholesterol	210 mg/dL	<200 mg/dL
LDL Cholesterol	128 mg/dL	<100 mg/dL
HDL Cholesterol	52 mg/dL	>50 mg/dL
Triglycerides	150 mg/dL	<150 mg/dL
Creatinine	0.9 mg/dL	0.6-1.1 mg/dL
eGFR	85 mL/min/1.73m²	>60 mL/min/1.73m²

Imaging Studies

Chest X-ray (15 July 2024)

Indication: Annual diabetes check-up

Findings: Clear lung fields bilaterally. No evidence of consolidation, effusion, or pneumothorax. Heart size within normal limits. No acute cardiopulmonary abnormality identified.

Mammogram (2 June 2024)

Indication: Routine screening

Findings: Bilateral breast tissue appears heterogeneously dense, which may obscure small masses. No suspicious masses, architectural distortions, or concerning calcifications identified. BI-RADS Category 2: Benign finding.

Immunizations

Vaccine	Date Administered	Next Due Date
Influenza	1 October 2023	October 2024
Tdap	15 May 2020	15 May 2030
Pneumococcal (PPSV23)	3 June 2023	N/A
Shingrix (RZV)	1st dose: 10 January 2024	2nd dose due: 10 July 2024

Recent Encounters

Primary Care Visit (10 August 2024)

Chief Complaint: Routine follow-up for diabetes and hypertension

Assessment: 39-year-old female with history of Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia presenting for routine follow-up. Blood pressure slightly elevated today at 138/88 mmHg. Recent HbA1c shows suboptimal glycemic control at 7.2%. Lipid panel shows elevated LDL cholesterol.

Plan:

Increase Lisinopril to 20 mg daily for better blood pressure control.
Adjust diabetes management: Increase Metformin to 1000 mg three times daily. Educate on importance of diet and exercise.
Increase Atorvastatin to 40 mg daily for better lipid control.
Recommend weight loss of 5-10% of body weight.
Schedule follow-up in 3 months with repeat HbA1c and lipid panel.
Referral to Registered Dietitian for medical nutrition therapy.

Ophthalmology Visit (5 July 2024)

Indication: Annual diabetic eye exam

Findings: Visual acuity 20/20 OU with correction. Intraocular pressure within normal limits. Dilated fundus exam shows no evidence of diabetic retinopathy. Early nuclear sclerotic cataracts noted bilaterally, not visually significant at this time.

Plan: Continue annual screening. Return sooner if any visual changes noted.

Social History

Occupation: High school teacher
Marital Status: Married
Children: Two (ages 10 and 8)
Exercise: Occasional walks, 1-2 times per week
Diet: Reports frequent consumption of processed foods and sugary drinks
Smoking: Never smoker
Alcohol: Social drinker, 2-3 glasses of wine per week
Substance Use: Denies any illicit drug use

Care Team

Provider	Specialty	Contact
Dr. Emily Chen	Primary Care Physician	555-0123
Dr. Michael Rodriguez	Endocrinologist	555-0124
Dr. Sarah Thompson	Ophthalmologist	555-0125
Lisa Johnson, RD	Registered Dietitian	555-0126

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