GeriCare Acute Template

Subjective:
Chief Complaint:
Follow-up diabetes management

HPI:
Mr. Johnson presents for follow-up of diabetes management. He reports feeling generally well with occasional fatigue. He denies new symptoms such as dizziness, vision changes, or increased urinary frequency, but does note intermittent numbness in his toes. He monitors his blood glucose at home approximately three times per week, with morning values typically between 7 and 8 millimoles per liter. He adheres to his prescribed medications, metformin and gliclazide, without difficulty. He maintains a balanced diet and engages in regular walking for physical activity. No recent falls or episodes of hypoglycemia are reported. This visit is medically necessary for ongoing management of diabetes mellitus.

Past Medical History:
Endocrine & Metabolic: Diabetes mellitus
No other significant past medical history provided.

Social History:
No social history provided.

Current Medications:
1. Metformin [Prescription]
   - Dosage: Not specified
   - Frequency: Morning and evening
   - Route: Not specified
   - Special Instructions: No problems with taking medications
2. Gliclazide [Prescription]
   - Dosage: Not specified
   - Frequency: Morning and evening
   - Route: Not specified
   - Special Instructions: No problems with taking medications

Allergies:
No allergy information provided.

Review of Systems (ROS):
Constitutional: Reports occasional fatigue.
Neurological: Reports intermittent numbness in toes.
Eyes: No vision changes reported.
Genitourinary: No increased urinary frequency reported.
No other systems reviewed.

Objective:
Vitals:
No vital signs provided.

Physical Exam:
No physical examination findings provided.

Assessment and Plan:
Assessment/Treatment Plan:
Diagnosis:
1. E11.9: Type 2 diabetes mellitus without complications (Glycated hemoglobin measured at 7.2 percent, stable renal function and cholesterol. No medication changes recommended. Continue current regimen. Arrange foot examination at next visit due to reported numbness in toes. Reinforce use of supportive footwear. Repeat laboratory monitoring in approximately three months. No questions or concerns raised by the patient.)
Time spent during the visit included face-to-face examination, review of laboratory results, medication adherence assessment, counseling on diet and activity, and documentation.