Example Transformation
Before
54 yo male here for follow up HTN and HLD. Feeling well overall. No chest pain or SOB. BP at home generally 130s/80s. Taking lisinopril and atorvastatin. Discussed continuing medications
and lifestyle modification. Follow up in 3 months.
After
Clinical Summary
Patient seen for follow-up of hypertension and hyperlipidemia. Reports feeling well overall without chest pain or shortness of breath.
Home blood pressures generally in the 130s/80s.
Key Problems
• Hypertension – controlled
• Hyperlipidemia – stable
Follow-Up Items
• Continue lisinopril and atorvastatin
• Lifestyle modification
• Follow up in 3 months
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