Clinical Summary

Mr. Robert presents for follow-up of type 2 diabetes mellitus and hypertension. He reports efforts to keep his blood sugars and blood pressure under control by improving his diet and increasing physical activity, specifically walking more. He denies any side effects from his current medications.

Past Medical History: History of type 2 diabetes mellitus and hypertension.

Allergies: No known drug allergies.

The treatment plan includes continuing the current regimen of metformin and ramipril. The patient is advised to maintain a high-fibre, low-glycemic diet, avoid sugary drinks, and reduce sodium intake to approximately one teaspoon per day, including processed and restaurant foods. He is encouraged to continue regular walking and add light strength training twice weekly if possible. The patient is instructed to keep a log of home blood glucose readings and bring it to the next visit. A referral to a dietitian for personalized dietary guidance has been made. Laboratory tests will be repeated in three months. The importance of achieving targets—HbA1c under 7 percent, blood pressure under 130/80 mmHg, and LDL cholesterol under 2.0 mmol/L—was reinforced.