General Adult Female PE

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

History of Present Illness:
Michael presents for follow-up of diabetes and hypertension management. He reports that he has been trying to keep his blood glucose and blood pressure under control by eating better and walking more. He confirms adherence to metformin and ramipril with no side effects from metformin and ramipril.

Past Medical History:
No changes to past medical history were discussed.

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

Allergies:
No allergies.

Objective:
Vital Signs:
Blood pressure is 138/84 millimeters of mercury. Weight is 84 kilograms. Body mass index is 28.3.

Physical Examination:
- Cardiovascular: Heart sounds are normal.
- Respiratory: Lungs are clear to auscultation.
- Abdomen: Abdomen is soft, no abdominal tenderness.
- Extremities: No ankle swelling.
- Neurologic: Foot sensation is intact, no foot ulcers or skin issues.

Test Results:
- Lipid Panel: Low-density lipoprotein is 2.4 millimoles per liter, triglycerides are 1.8 millimoles per liter.
- Hemoglobin A1C: 7.2 percent.
- Fasting glucose: 7.8 millimoles per liter.

Assessment:
Problem:
Other specified health status (Z78.9): Stable
Encntr for hlth suprvsn and care of healthy infant and child (Z76.2): Up to date
Oth conditions originating in the perinatal period (P96.89): Type 2 diabetes mellitus and hypertension, both under ongoing management with stable laboratory and examination findings.

Plan:
- Medications: Continue metformin and ramipril as prescribed
- Follow-up: Repeat laboratory tests in 3 months; bring home glucose log to next visit
- Patient Education:
  - Follow a balanced diet rich in high-fiber, low-glycemic foods; avoid sugary drinks
  - Limit sodium intake to about 1 teaspoon per day, including processed foods; read food labels for sodium content and use herbs for flavor instead of salt
  - Engage in regular walking and add light strength training twice a week if possible
  - Maintain a healthy weight and monitor blood pressure at home
- Referral to dietitian for personalized dietary guidance

Dr. Johnson
Regional Medical Center