Family general Template

Subjective:
1. Type 2 Diabetes Mellitus:
- Richard reports he has been trying to keep his blood glucose under control by eating better and increasing physical activity, specifically walking more.
- He confirms adherence to metformin therapy with no side effects from the medication.
- No known drug allergies are reported.
- He monitors his blood glucose at home approximately three times per week, usually in the morning.
- There is a recent change in family history: Richard's younger brother has been diagnosed with diabetes.

2. Hypertension:
- Richard states he is making efforts to control his blood pressure.
- He confirms daily use of ramipril with no side effects.
- No known drug allergies are reported.
- He expresses uncertainty about appropriate salt intake and receives education regarding sodium restriction.

Objective:
- BP: 138/84 mmHg (slightly elevated, improved from previous visit)
- Weight: 84 kg
- BMI: 28.3
- Fasting glucose: 7.8 mmol/L
- HbA1c: 7.2%
- LDL: 2.4 mmol/L
- Triglycerides: 1.8 mmol/L
- Heart sounds: normal
- Lungs: clear
- No ankle swelling
- Abdomen: soft, no tenderness
- Foot sensation: intact
- No foot ulcers or skin issues

Assessment:
1. Type 2 Diabetes Mellitus (E11.9): Glycemic control is stable with recent HbA1c at 7.2%. Richard is adherent to metformin and self-monitoring blood glucose. Family history is notable for a new diagnosis of diabetes in his younger brother.
- DDx:
• Type 2 diabetes mellitus: Supported by laboratory findings and ongoing management.
• Secondary causes of hyperglycemia: Less likely given stable control and absence of new symptoms.

2. Essential Hypertension (I10): Blood pressure is slightly above target at 138/84 mmHg. Richard is adherent to ramipril and is making dietary and lifestyle modifications.
- DDx:
• Essential hypertension: Supported by history and current readings.
• Secondary hypertension: No evidence of secondary causes based on history and examination.

Plan:
1. Type 2 Diabetes Mellitus:
- Continue metformin as prescribed.
- Refer to dietitian for personalized dietary guidance.
- Advise Richard to maintain a log of home blood glucose readings and bring it to the next visit.
- Reinforce dietary recommendations focusing on high-fibre, low-glycemic foods and avoidance of sugary drinks.
- Encourage ongoing physical activity, including walking and light strength training twice weekly if possible.
- Repeat laboratory investigations in 3 months.

2. Essential Hypertension:
- Continue ramipril as prescribed.
- Educate on sodium restriction, limiting salt intake to approximately 1 teaspoon per day including processed and restaurant foods.
- Advise reading food labels and choosing low sodium or no added salt products.
- Recommend use of herbs and spices for flavor instead of salt.
- Reinforce importance of blood pressure control to reduce risk of cardiovascular and renal complications.
- Follow up at next scheduled visit.

Clinic Name: Regional Medical Center