Consultation Summary
Review your consultation details and recommendations
SJ
Dr. Sarah Johnson
Cardiologist
Chief Complaint
Follow-up for hypertension management. Patient reports occasional headaches and fatigue.
Clinical Notes
Vital Signs
Blood Pressure
135/85 mmHg
Heart Rate
78 bpm
Weight
165 lbs
Assessment
Blood pressure shows slight elevation. Current medication appears to be working but may need adjustment. Patient is compliant with treatment plan.
Prescription
Rx
Lisinopril 20mg
Take 1 tablet daily in the morning
Duration: 90 days
Rx
Aspirin 81mg
Take 1 tablet daily with food
Duration: 90 days
Lab Tests Ordered
Comprehensive Metabolic Panel
To be done within 2 weeks
Lipid Panel
To be done within 2 weeks
Recommendations & Follow-up
Lifestyle Modifications
- Reduce sodium intake to less than 2000mg per day
- Engage in moderate aerobic exercise for 30 minutes, 5 days a week
- Monitor blood pressure at home daily
- Maintain healthy weight through balanced diet
Follow-up
Schedule follow-up appointment in 4 weeks to review lab results and blood pressure trends.
Referral
Cardiology Specialist
For advanced cardiac evaluation if BP remains elevated