MEDICORE REGIONAL HOSPITAL Department of Internal Medicine Medical Report — Confidential ================================================================ Patient ID: P-1001 Full Name: James R. Mitchell Date of Birth: 1978-03-14 Gender: Male Blood Type: A+ Ward: General Medicine — Room 204 Attending: Dr. Priya Nambiar, MD Report Date: August 4, 2026 ================================================================ CHIEF COMPLAINT: Patient presents with persistent fatigue, mild dyspnea on exertion, and intermittent chest discomfort over the past 3 weeks. HISTORY OF PRESENT ILLNESS: Mr. Mitchell is a 48-year-old male with a history of type 2 diabetes (HbA1c 7.4% at last check) and hypertension (controlled on Amlodipine 5mg). He reports worsening fatigue over 3 weeks with mild breathlessness climbing stairs. Denies chest pain at rest, palpitations, or syncope. VITAL SIGNS: BP: 138/88 mmHg Pulse: 82 bpm (regular) SpO2: 96% (room air) Temp: 37.1°C Weight: 87 kg BMI: 28.4 ASSESSMENT & PLAN: 1. Suspected early heart failure — echocardiogram ordered 2. Diabetic nephropathy screening — urine ACR pending 3. Continue current antihypertensives; dose review in 2 weeks 4. Cardiology referral placed (urgent) 5. Patient advised to restrict sodium to <2g/day FOLLOW-UP: August 18, 2026 with cardiology ATTENDING SIGNATURE: Dr. Priya Nambiar #47291