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ABC Health Clinics
123 First Street, Cleveland, Ohio

SUBJECTIVE: This is a 46-year-old black female, ambulatory to clinic, and in no acute distress. She is here                   complaining of hypertension and gives a history of congestive heart failure. It has been about two                   years since the patient has been in this clinic and has been seeing another provider who wanted her                   to have a chest x-ray, which she failed to have done. She denies any kind of shortness of breath or                   chest pain at this time. She does relate having episodes of chest pain which has been evaluated by                   her previous provider.

OBJECTIVE: Alert, active, ambulatory, afebrile and in no acute distress. No JVD or carotid bruits. Lungs are                   clear to auscultation. Heart rate and rhythm are regular without murmur, S3 or S4. Abdomen is soft                   without bruits or tenderness. Bowel sounds are present. Lower extremities are without edema.

ASSESSMENT: Hypertension – benign.

PLAN: Continue current medication regimen without change. Return to clinic to evaluate chest x-ray result in two         to three days or sooner certainly p.r.n.