Geriatric Comprehensive Assessment

History:
Mr. Robert presents for follow-up of type 2 diabetes mellitus and hypertension. He reports efforts to control blood sugars and blood pressure through improved diet and increased physical activity, specifically walking more. He denies medication side effects and confirms adherence to his prescribed regimen. His younger brother was recently diagnosed with diabetes.

Medical History:
The patient has a history of type 2 diabetes mellitus and hypertension.

Physical Examination:
Blood pressure is 138/84 mmHg. Weight is 84 kg. BMI is 28.3. Cardiac examination reveals normal heart sounds. Pulmonary examination reveals clear lungs. There is no ankle swelling. Abdominal examination reveals a soft, non-tender abdomen. Foot examination reveals intact sensation with no ulcers or skin issues.

Investigations:
Fasting glucose is 7.8 mmol/L. Recent HbA1c is 7.2%. LDL cholesterol is 2.4 mmol/L. Triglycerides are 1.8 mmol/L.

Impression:
1. Type 2 diabetes mellitus without complications (E11.9)
2. Essential (primary) hypertension (I10)
3. Other hyperlipidemia (E78.49)

Plan and Recommendations:
Continue current medications (metformin and ramipril) as prescribed. Refer to dietitian for personalized dietary guidance. Advise patient to maintain a high-fibre, low-glycemic diet, avoid sugary drinks, and reduce sodium intake to approximately 1 teaspoon per day. Encourage continuation of regular walking and addition of light strength training twice weekly. Instruct patient to keep a home blood glucose log and bring it to the next visit. Repeat laboratory tests in 3 months. Reinforce importance of controlling A1c, blood pressure, and LDL to target levels.