HH Abdominal Pain Note

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

History of Present Illness:
Mr. Thomas is a middle-aged male presenting for follow-up of diabetes and hypertension management. He reports that he has been trying to keep his blood sugar and blood pressure under control. He states that he has been eating better and walking more. He confirms that he is taking metformin and ramipril daily without any side effects. He denies any known allergies. He reports no recent changes in his own health but notes that his younger brother was recently diagnosed with diabetes. Mr. Thomas monitors his blood glucose at home about three times a week, usually in the morning. He has no other symptoms or concerns reported at this time.

Past Medical History:
No history of previous abdominal surgeries or chronic gastrointestinal diseases.

Past Surgical History:
There is no surgical history reported by Mr. Thomas.

Family History:
No significant family history of gastrointestinal diseases.

Social History:
Mr. Thomas reports that he has been eating better and walking more. No information regarding alcohol consumption or tobacco use provided.

Current Medications:
Metformin and ramipril are taken daily. No side effects from metformin and ramipril.

Allergies:
No allergies.

Objective:
Vital Signs:
Blood pressure is 138/84 mmHg. Weight is 84 kg. Body mass index is 28.3.

Physical Examination:
General Appearance: Mr. Thomas is alert, cooperative, and appears comfortable at rest.
ENT Examination: No abnormalities described.
Respiratory Examination: Lungs are clear to auscultation.
Neurological Examination: Foot sensation is intact. No ankle swelling. No abdominal tenderness. No foot ulcers or skin issues.

Test Results:
Fasting glucose is 7.8 mmol/L. Hemoglobin A1c is 7.2%. Low-density lipoprotein is 2.4 mmol/L. Triglycerides are 1.8 mmol/L.

Assessment:
Problem:
Acute abdomen (R10.0), unspecified etiology.

Differential Diagnosis:
No differential diagnoses discussed or documented.

Plan:
No plan documented.