Gyne Consult

Thank you for referring Mr. Robert, whom I saw in clinic on 2026-01-23 for follow-up of type 2 diabetes mellitus and hypertension.

History of Current Concern:
Mr. Robert reports that he has been trying to keep his blood sugars and blood pressure under control. He has been making efforts to eat better and increase his physical activity by walking more. He denies any side effects from his current medications. He monitors his blood glucose at home approximately three times per week, usually in the morning.

Medical History:
- Type 2 diabetes mellitus
- Hypertension

Medications:
1. Metformin
2. Ramipril

Allergies:
- Denies any known drug allergies

Family History:
- The patient's younger brother was recently diagnosed with diabetes

Labwork/Investigations:
- Fasting glucose: 7.8 mmol/L
- HbA1c: 7.2%
- LDL cholesterol: 2.4 mmol/L
- Triglycerides: 1.8 mmol/L

Physical Exam:
- Cardiovascular: Heart sounds are normal. No ankle swelling observed.
- Respiratory: Lungs are clear to auscultation.
- Abdomen: Abdomen is soft and non-tender.
- Neurological: Foot sensation is intact.
- Skin: No ulcers or skin issues present.

Impression and Plan:
- Mr. Robert is a patient with:
  1. Type 2 diabetes mellitus without complications
  2. Essential (primary) hypertension
  3. Hyperlipidemia, unspecified