Medical Report Example From a Doctor

Patient Information

• Name: David Lee
• Age: 50
• Date of Birth: March 5, 1973
• Gender: Male
• Patient ID: 008765432

Report Details

• Report Date: October 14, 2023
• Doctor’s Name: Dr. Sarah Thompson
• Healthcare Facility: Riverside Health Clinic

Medical History

• Current Conditions: Type 2 Diabetes, High Blood Pressure
• Past Medical History: Appendectomy (2005), High Cholesterol
• Allergies: None reported

Physical Examination Findings

• Vital Signs:
  • Blood Pressure: 140/90 mmHg
  • Heart Rate: 80 bpm
  • Blood Glucose (Fasting): 160 mg/dL
• General Observations: Mild fatigue, occasional dizziness

Diagnosis

• Primary Diagnosis: Type 2 Diabetes
• Secondary Diagnoses: Hypertension and Hyperlipidemia

Treatment Plan

• Medications:
  • Metformin 500 mg, twice daily
  • Amlodipine 5 mg, once daily for blood pressure
  • Atorvastatin 20 mg, once daily for cholesterol
• Lifestyle Recommendations:
  • Follow a low-carb, low-sodium diet
  • Exercise regularly, at least 30 minutes daily

Follow-Up Instructions

• Next Appointment: Scheduled for December 14, 2023
• Monitoring: Daily blood sugar checks; monitor blood pressure weekly. Report any adverse symptoms immediately.

Doctor’s Signature

• Dr. Sarah Thompson
• License Number: 56473829
• Contact Information: (555) 123-4567, [email protected]