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Maria Cole

Annual check-up & medication review

Submitted
Apr 10, 2026
Assessments
2
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, body, and mind context.

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

Demographics

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

ICD I10

Status: Controlled
Severity: Stage 1

Plan

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Medications
Testing
Referrals
Lifestyle
Monitoring
Follow-up
Preventive Care

Hyperlipidemia

ICD E78.5

Status: Controlled
Severity: Moderate Risk

Plan

Click any line to refine it.

Medications
Testing
Referrals
Lifestyle
Monitoring
Follow-up
Preventive Care