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PATIENT MEDICAL RECORD

Ref: MR-2025-05-17-001
Date: 17 May 2025
Time: 09:30 AM
Patient Name:John Smith
DOB:12 Jan 1980
Patient ID:P-12345
Gender:Male

CHIEF COMPLAINT

Patient presents with persistent headache for the past 3 days, accompanied by mild fever.

HISTORY OF PRESENT ILLNESS

Headache began gradually and has increased in intensity. Patient reports pain is concentrated...

PHYSICAL EXAMINATION

Vital signs: BP 130/85, HR 78, Temp 37.8°C. Patient appears mildly distressed...

ASSESSMENT

1. Acute sinusitis, likely viral in origin

2. Dehydration, mild

PLAN

1. Recommend rest and increased fluid intake

2. Acetaminophen 500mg every 6 hours as needed for pain and fever

3. Follow up in 3 days if symptoms persist or worsen

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Record

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2

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3

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