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PATIENT MEDICAL RECORD

Ref: MR-2025-05-17-001
17 May 2025
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...

PLAN

Acetaminophen 500mg q6h; Follow up in 3 days.

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