Depression Assessment

Subjective:
Chief Complaint:
Follow-up for diabetes and hypertension management

History of Present Illness:
Richard presents for follow-up of diabetes and hypertension management. He reports feeling okay and is actively trying to keep his blood glucose and blood pressure under control. He has been making efforts to eat better and walk more. He tests his blood glucose at home about three times a week, usually in the morning. He denies any known allergies, ankle swelling, abdominal tenderness, or foot ulcers or skin issues.

Past Psychiatric History:
No psychiatric history provided.

Family History:
Richard's younger brother was recently diagnosed with diabetes.

Social History:
No social history provided.

Objective:
Medications:
Richard is currently taking metformin and ramipril daily for diabetes and hypertension management. He reports no medication side effects.

Disclaimer:
Billing codes are only intended as a guide. It is the healthcare provider's responsibility to ensure their appropriateness and accuracy for each consultation.