HH MD SOAP NOTE

Subjective:
Reason:
**Reason:**
F/U DM & HTN mgmt; pt seen alone

**Subjective:**
- CC: F/U DM & HTN mgmt
- HPI: [Fictional Name] reports efforts to control BG & BP; adheres to metformin & ramipril daily; ↑ exercise & dietary changes; no med side effects; no known allergies; recent FHx: younger brother dx w/ DM

Objective:
**Objective:**
- Physical exam findings: Heart S1/S2 N, lungs clear, no ankle swelling, ABD soft, no abdominal tenderness, foot sensation intact, no foot ulcers or skin issues
- Vital signs: BP 138/84 mmHg (↑), Wt 84 kg, BMI 28.3, No apparent distress
Head and N: N
CVS: N heart sounds
Resp: Clear
ABD: Soft, NT
MSk: N
Neurological: Foot sensation intact
Skin: No ulcers/skin issues
GU: 
- Lab results: FPG 7.8 mmol/L (↑), HbA1c 7.2% (↑), LDL 2.4 mmol/L (↑), TG 1.8 mmol/L (↑)
- Imaging findings: 
- Other measurable data: 

Assessment:
- DM2: suboptimal glycemic ctrl (HbA1c 7.2%, FPG 7.8↑)
- HTN: suboptimal BP ctrl (138/84↑)
- Dyslipidemia: LDL 2.4↑, TG 1.8↑
- FHx DM (brother)

Diagnoses and Differential Diagnoses with ICD-9 Codes:
- 250.0 Diabetes mellitus type 2 (E11)
- 401.9 Essential hypertension (I10)
- 272.4 Hyperlipidemia (E78.49)

Plan:
Plan::
1:
- Continue metformin & ramipril
- Reinforce dietary advice: ↑ fiber, ↓ glycemic index, ↓ Na+ (<1 tsp/d), avoid sugary drinks
- Encourage regular exercise: walking + add light strength training x2/wk
- Refer to dietitian for individualized counseling
- Continue home BG monitoring; bring log next visit
- Repeat labs in 3 mo
- Educate on reading food labels & using herbs for flavor
- Monitor for complications (CVD, renal, foot)
- Reinforce importance of risk factor mgmt due to FHx