FSM PRE-VISIT ASSESSMENT AND TENTATIVE PLAN

FSM PRE-VISIT ASSESSMENT AND TENTATIVE PLAN :
• Clinician pre-prepared the visit by reviewing the chart prior to the visit. • The AI scribe note is a summary previsit planning

Subjective:
REASON FOR VISIT:
David is a male with diabetes mellitus type 2, hypertension, hyperlipidemia, and overweight status presenting for follow-up of diabetes and hypertension management.

HISTORY OF PRESENT ILLNESS:
- Diabetes mellitus type 2: Mr. David presents for follow-up of diabetes management. He reports adherence to metformin daily with no side effects. He monitors his blood glucose at home approximately three times per week, typically in the morning. His most recent laboratory results show a fasting glucose of 7.8 mmol/L and a hemoglobin A1c of 7.2%. He states he has been trying to eat better and increase physical activity, specifically by walking more. There are no reported medication side effects. There are no known allergies. Family history is notable for a younger brother recently diagnosed with diabetes.
  - Current medication: Metformin

- Hypertension: Mr. David is also being followed for hypertension. He reports taking ramipril daily with no side effects. His blood pressure today is 138/84 mmHg, which is slightly elevated but improved compared to his last visit. He is aware of the importance of dietary sodium restriction and is making efforts to reduce salt intake. There are no reported medication side effects. There are no known allergies.
  - Current medication: Ramipril

- Hyperlipidemia: Recent cholesterol panel shows LDL at 2.4 mmol/L and triglycerides at 1.8 mmol/L, both slightly above target but stable. He is not currently on lipid-lowering medication.

- Weight: Current weight is 84 kg with a body mass index of 28.3.

Assessment and Plan:
ASSESSMENT AND PLAN:
1. Diabetes mellitus type 2: Fasting glucose is 7.8 mmol/L, hemoglobin A1c is 7.2%. David reports adherence to metformin with no side effects and monitors blood glucose at home. 
 • Continue metformin as prescribed.
 • Encourage ongoing dietary modifications focusing on high-fibre, low-glycemic foods and avoidance of sugary drinks.
 • Recommend continued physical activity, including walking and addition of light strength training twice weekly.
 • Refer to dietitian for personalized dietary guidance.
 • Repeat laboratory testing in 3 months.
 • No ankle swelling, no abdominal tenderness, no foot ulcers or skin issues noted on examination.

2. Hypertension: Blood pressure is 138/84 mmHg. David reports adherence to ramipril with no side effects and is making efforts to reduce sodium intake. 
 • Continue ramipril as prescribed.
 • Advise limiting sodium intake to approximately 1 teaspoon per day, including processed and restaurant foods.
 • Encourage use of herbs and spices for flavor instead of salt.
 • Monitor blood pressure and reinforce home monitoring if available.
 • No ankle swelling, no abdominal tenderness, no foot ulcers or skin issues noted on examination.

3. Hyperlipidemia: LDL is 2.4 mmol/L, triglycerides are 1.8 mmol/L. Not currently on lipid-lowering medication. 
 • Reinforce dietary modifications to further reduce LDL and triglycerides.
 • Monitor lipid panel at next laboratory assessment.
 • No ankle swelling, no abdominal tenderness, no foot ulcers or skin issues noted on examination.

4. Overweight: Weight is 84 kg, body mass index is 28.3. 
 • Encourage ongoing physical activity and dietary modifications to support weight reduction.
 • Monitor weight and body mass index at follow-up.
 • No ankle swelling, no abdominal tenderness, no foot ulcers or skin issues noted on examination.

-considered appropriate privacy and security, patient informed about use of AI scribe 
-provided informed consent and gave permission to AI scribe 
-accuracy of note was verified and final approval by clinician. 
S

Regional Medical Center