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Maria Cole

Submitted: 4/10/2026

Subjective

Chief Complaint: Annual check-up & medication review

History of Present Illness: Patient feels generally well. Reports occasional stress-related headaches.

Review of Systems: General: No fever, chills. CV: No chest pain. Resp: No SOB.

Past Medical History: Hypertension (diagnosed 2022), Hyperlipidemia (diagnosed 2022)

Medications: Lisinopril 10mg daily, Atorvastatin 20mg daily

Social History

Environment: Stable housing, Accountant, No SDOH, No Exposures

Body: Balanced diet, walks 30 mins 3x/week, no substance use

Mind: High stress during tax season, good family support, stable relationships

Objective

Age: Age 42

Vitals: BP 130/85, HR 72, Wt 150 lbs, Ht 5'5"

Physical Exam: WDL

Labs & Imaging: A1c 5.5%, Lipid Panel: LDL 95, HDL 50, Total 160

Risk Scores: ASCVD 2.5% (Low)

Assessment & Plan

Hypertension (I10)

Status: Controlled
Severity: Stage 1
Plan
Medications:

Continue Lisinopril 10mg daily.

Testing:

Lipid panel annually.

Referrals:

None needed.

Lifestyle:

Counsel on continued low sodium diet. Encourage increase to 5x/week. Discuss stress management techniques.

Monitoring:

Check BP weekly. Report any dizziness.

Follow-up:

3 months. Goal: BP < 130/80

Preventive Care:

Annual flu shot.

Hyperlipidemia (E78.5)

Status: Controlled
Severity: Moderate Risk
Plan
Medications:

Continue Atorvastatin 20mg daily.

Testing:

None needed at this time.

Referrals:

None

Lifestyle:

Reinforce heart-healthy diet.

Monitoring:

Annual lipid panel. Report muscle pain.

Follow-up:

3 months. Goal: LDL < 100

Preventive Care:

Discussed aspirin therapy, patient declined.