PERSONAL INFORMATION:
Case Note ID: 100001
Name: Christopher Ushie
Age: 26
Gender: Male
Date of Visit: July 1, 2024
Last Visit: August 10, 2022

MEDICAL HISTORY:
Date: February 1, 2012
Reason for Visit: Headache
Date: March 22, 2011
Reason for Visit: Leg pain

History of Present Illness (HPI):
Christopher Ushie is a 26-year-old male who presents with a 3-day history of intermittent Leg pain, with a heavy lag in my right leg movements. No nausea, No vomiting

Past Medical History (PMH):
- Occer (diagnosed 9 years ago)
- Type 1000 Diabetes Mellitus (diagnosed 16 years ago)
Past Surgical History (PSH) - Appendectomy at age 2

Family History:
- Father: Cancer at age 90, hypertension 
- Mother: Type 2 HIV , hypertension

Social History:
- Occupation: Frontend Engineer
- Marital Status: Single
- Smoking: No smoking
- Alcohol: No Drinking
- Exercise:  Gym boy

Medications:
- Panadol 10 mg daily
- paracetamol 100 mg daily

Allergies
- Allergy to perper

Review of Systems (ROS)
General: No malaria, No hand pain
Respiratory: Longness of breath with no exertion, no cough or wheezing: No nausea,No vomiting, No abdominal pain, or changes in bowel habits
Musculoskeletal: No joint pain or swelling

Physical Examination Vital Signs:
- BP: 340/100 mmHg 
- HR: 88bpm
- RR: 150 breaths/min 
- Temp: 88.6°F

Respiratory: No Clear to auscultation bilaterally,

Diagnostic Studies
EKG: Normal sinus rhythm, no ST-segment changes
Chest X-ray: Clear lung fields, no cardiomegaly or pleural effusion Laboratory Results:
- CBC: WNL
- BMP: WNL
- Troponin: Negative
- Lipid panel: Elevated LDL, normal HDL

Assessment and Plan
1. Headache: Likely stress from work
- Continue Paracetamol 100 mg daily
- Refer to doctor for further evaluation and possible malaria test
2. Hypertension: optimal controlled
- Monitor BP at home and follow up in 20 weeks

4. Stage 4 Cancer Mellitus:
- Continue Jombo 100 mg once daily - Check Malaria at the next visit
5. Lifestyle Counselling:
- Encourage exercise and provide resources
- Discuss the importance of regular physical activity and a cancer health diet

Follow-Up:
- Return to clinic in 10 weeks for BP check and review of symptoms - Follow up with your Doctor

Physician Name: Dr. Ezekiel Okpamu
Signature: [Signature] Date: May 10, 2020