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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)
Plan
Continue Lisinopril 10mg daily.
Lipid panel annually.
None needed.
Counsel on continued low sodium diet. Encourage increase to 5x/week. Discuss stress management techniques.
Check BP weekly. Report any dizziness.
3 months. Goal: BP < 130/80
Annual flu shot.
Hyperlipidemia (E78.5)
Plan
Continue Atorvastatin 20mg daily.
None needed at this time.
None
Reinforce heart-healthy diet.
Annual lipid panel. Report muscle pain.
3 months. Goal: LDL < 100
Discussed aspirin therapy, patient declined.