HH MD SOAP NOTE

Subjective:
Reason:
**Reason:**
F/U DM & HTN mgmt, review labs (HbA1c ↑, BP ↑), assess med adherence, address FHx DM, reinforce lifestyle mods.

**Subjective:**
- CC: F/U for DM & HTN mgmt
- HPI: Alex reports feeling okay, actively working on glycemic and BP control, adheres to metformin and ramipril daily, no medication side effects, no known allergies. Reports increased physical activity and dietary efforts. Family history updated: younger brother recently diagnosed with DM.

Objective:
**Objective:**
- Physical exam findings: Heart sounds normal, lungs clear, abdomen soft, foot sensation intact. No ankle swelling, no abdominal tenderness, no foot ulcers or skin issues.
- Vital signs: BP 138/84 mmHg (↑), weight 84 kg, BMI 28.3
- Lab results: Fasting glucose 7.8 mmol/L, HbA1c 7.2%, LDL 2.4 mmol/L, triglycerides 1.8 mmol/L
- Imaging findings: 
- Other measurable data: 

Assessment:
- T2DM (E11): Glycemic control stable (HbA1c 7.2%), FBG ↑, on metformin, no side effects
- HTN (I1A): BP mildly ↑ (138/84 mmHg), on ramipril, no side effects
- Dyslipidemia (E78.49): LDL ↑ (2.4 mmol/L), TG ↑ (1.8 mmol/L)
- BMI ↑ (28.3) overweight

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 as prescribed
- Continue ramipril as prescribed
- Reinforce dietary modifications: high-fibre, low-glycemic foods, limit sodium to ~1 tsp/day, avoid sugary drinks
- Encourage regular physical activity: walking and add light strength training twice weekly
- Refer to dietitian for personalized nutrition guidance
- Advise home blood glucose monitoring and keep a log
- Repeat laboratory tests in 3 months

Dr. Jamie Carter
Regional Medical Center