Endo Thyroid Intake - Adult

Subjective:
Chief Complaint:
Follow-up for diabetes management

History of Present Illness:
Mr. Carter is a male patient presenting for follow-up of diabetes management. Since the last visit, he reports feeling generally well, with occasional mild fatigue. He denies experiencing dizziness, vision changes, increased urinary frequency, or episodes of hypoglycemia such as shakiness, diaphoresis, or lightheadedness. He does note intermittent numbness in his toes. Mr. Carter monitors his capillary blood glucose at home approximately three times per week, with typical morning values ranging from 7 to 8 millimoles per liter. He remains adherent to his prescribed medications, metformin and gliclazide, without adverse effects. Dietary habits have improved, with increased vegetable intake, and he engages in regular ambulation most days. He denies recent falls or significant unsteadiness, though he reports mild slowness when rising from a seated position. Recent laboratory investigations revealed a hemoglobin A1c of 7.2 percent, with stable renal function and lipid profile. These symptoms have not significantly impacted his daily activities. He denies polyuria, polydipsia, unexplained weight changes, or other endocrine symptoms.

Past Medical History:
No significant findings.

Family History:
No family history provided.

Social History:
Mr. Carter reports increased vegetable intake and regular ambulation most days. He lives with his wife, who assists with dietary management and monitoring of his health. No information provided regarding occupation, smoking status, alcohol use, or drug use.

The Review of Systems:
Constitutional – No fever, chills, weight loss, weight gain, night sweats, or weakness. Mild fatigue reported.

Eyes – No double vision, no blurry vision, wears glasses, no dry eyes, no vision changes.

Integumentary – No rashes, dry skin, or eczema, no increased sweating.

Cardiovascular – No chest pain, heart palpitations, dizziness.

Respiratory – No shortness of breath, no cough, no wheezing.

Gastrointestinal – No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating.

Genito Urinary – No dysuria, hematuria, frequency, urgency. No changes to menstruation, no changed libido. No increased trips to the bathroom.

Musculoskeletal – No muscle aches, muscle weakness, joint tenderness, redness or swelling.

Neurological – No tremor, no headaches or weakness, no sensory changes, no numbness or tingling in hands/fingers, no history of seizures. No tingling in feet. Reports intermittent numbness in toes. No feeling shaky, no feeling sweaty, no feeling lightheaded.

Psychology – No changes in mood, no anxiety, no sleep disturbances, no irritability, impaired concentration.

Allergies:
No allergies reported.

Current Medications:
Metformin, taken every morning and evening. Gliclazide, taken every morning and evening. No problems with medications.

Past Surgical History:
No past surgical history provided.

Objective:
Physical Examination:
Constitutional – Patient is alert and appears well, in no acute distress.

HEENT – Head atraumatic and normocephalic, extraocular movements intact, pupils equal, round, and reactive to light and accommodation, no oral lesions.

Neck – Thyroid not enlarged, feels soft and symmetrical with no palpable nodules, no tenderness, normal movement on swallowing. No lymphadenopathy, trachea midline.

Cardiovascular – Regular rate and rhythm, normal heart sounds with no murmurs or added sounds, no jugular venous distension. No peripheral edema, capillary refill time less than 2 seconds.

Respiratory – Clear to auscultation bilaterally, no wheezes or crackles.

Abdomen – Soft, non-tender, no distension, no hepatosplenomegaly, normal bowel sounds.

Neurologic – Strength 5/5 in upper and lower extremities, normal gait, cranial nerves grossly intact.

Integumentary – No signs of dry skin, hair or nail brittleness, no hair loss, no rashes, lesions, or other significant skin changes.

Test Results:
Hemoglobin A1c measured at 7.2 percent. Renal function and lipid profile reported as stable. No additional laboratory or imaging results provided.

Vital Signs:
No vital signs provided.

Assessment:
Differential Diagnosis:
Type 2 diabetes mellitus with diabetic polyneuropathy (E11.42).

Problem:
Type 2 diabetes mellitus without complications (E11.9).

Clinical Impression:
Mr. Carter presents for follow-up of COVID-19 (U07.1). Glycemic control is reasonable with a hemoglobin A1c of 7.2 percent. He reports intermittent numbness in his toes, suggestive of mild peripheral neuropathy. No evidence of hypoglycemia or other acute complications.

Plan:
- Type 2 diabetes mellitus without complications (E11.9): Mr. Carter reported stable glycemic control with home capillary blood glucose measurements typically ranging from 7 to 8 millimoles per liter in the morning. He remains adherent to metformin and gliclazide without adverse effects. Hemoglobin A1c was 7.2 percent, which is within the individualized target range. He reported intermittent numbness in his toes but denied episodes of hypoglycemia, dizziness, vision changes, polyuria, polydipsia, or unexplained weight changes. Renal function and lipid profile were stable.
Plan:
• Continue current regimen of metformin and gliclazide at existing dosages.
• Continue home blood glucose monitoring several times per week.
• Maintain dietary modifications with increased vegetable intake and regular ambulation as tolerated.
• Arrange for a comprehensive foot examination at the next visit due to reported intermittent numbness in the toes.
• Advise use of supportive footwear at home to reduce risk of foot injury.
• Order repeat laboratory investigations, including hemoglobin A1c, renal function, and lipid profile in approximately three months.
• Schedule follow-up appointment in three months to review laboratory results and reassess diabetes management.
• Counselled Mr. Carter on the importance of medication adherence, regular physical activity, and foot care. Discussed the absence of hypoglycemic episodes and reinforced the need to monitor for symptoms such as shakiness, diaphoresis, or lightheadedness.
• Encouraged Mr. Carter to contact the clinic if he experiences any new symptoms, including worsening numbness, foot ulcers, or signs of hypoglycemia.


- Polyneuropathy, unspecified (G62.9): Mr. Carter reported intermittent numbness in his toes without associated pain or functional impairment.
Plan:
• Arrange for a focused foot examination at the next visit to assess for sensory deficits, skin integrity, and risk of ulceration.
• Advise continued use of supportive footwear.
• Monitor for progression of symptoms and reassess at next follow-up.


Follow Up:
Follow-up appointment scheduled in approximately three months. No questions or concerns.

Clinic Name: Regional Medical Center

Assessment and Plan:
- Type 2 diabetes mellitus without complications (E11.9): Mr. Carter reported stable glycemic control with home capillary blood glucose measurements typically ranging from 7 to 8 millimoles per liter in the morning. He remains adherent to metformin and gliclazide without adverse effects. Hemoglobin A1c was 7.2 percent, which is within the individualized target range. He reported intermittent numbness in his toes but denied episodes of hypoglycemia, dizziness, vision changes, polyuria, polydipsia, or unexplained weight changes. Renal function and lipid profile were stable.
Plan:
• Continue current regimen of metformin and gliclazide at existing dosages.
• Continue home blood glucose monitoring several times per week.
• Maintain dietary modifications with increased vegetable intake and regular ambulation as tolerated.
• Arrange for a comprehensive foot examination at the next visit due to reported intermittent numbness in the toes.
• Advise use of supportive footwear at home to reduce risk of foot injury.
• Order repeat laboratory investigations, including hemoglobin A1c, renal function, and lipid profile in approximately three months.
• Schedule follow-up appointment in three months to review laboratory results and reassess diabetes management.
• Counselled Mr. Carter on the importance of medication adherence, regular physical activity, and foot care. Discussed the absence of hypoglycemic episodes and reinforced the need to monitor for symptoms such as shakiness, diaphoresis, or lightheadedness.
• Encouraged Mr. Carter to contact the clinic if he experiences any new symptoms, including worsening numbness, foot ulcers, or signs of hypoglycemia.


- Polyneuropathy, unspecified (G62.9): Mr. Carter reported intermittent numbness in his toes without associated pain or functional impairment.
Plan:
• Arrange for a focused foot examination at the next visit to assess for sensory deficits, skin integrity, and risk of ulceration.
• Advise continued use of supportive footwear.
• Monitor for progression of symptoms and reassess at next follow-up.