HH MD SOAP NOTE (New)

Subjective:
- F/U DM & HTN mgmt
- Alex reports feeling generally well and is actively attempting to control blood glucose and blood pressure through dietary modifications and increased physical activity (walking). He confirms adherence to metformin and ramipril with no side effects. No known drug allergies. Reports no recent changes in symptoms. Family history updated: younger brother recently diagnosed with diabetes. Seen alone.

Objective:
Physical Exam:
- General: No Apparent Distress
- CVS: Heart sounds normal
- Respiratory: Lungs clear
- Abdomen: Soft, no tenderness
- Extremities: No ankle swelling
- Neurological: Foot sensation intact
- Skin: No foot ulcers or skin issues

Vital signs: BP 138/84 mmHg (slightly elevated), 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

Other measurable data: No abdominal tenderness, no ankle swelling, no foot ulcers or skin issues.

Assessment:
- DM2 (E11): Glycemic control stable (HbA1c 7.2%), FBG ↑ (7.8 mmol/L), target not yet achieved (A1c <7%)
- HTN (I1A): BP improved but still above target (138/84 mmHg), goal <130/80 mmHg
- Dyslipidemia (E78.49): LDL 2.4 mmol/L, TG 1.8 mmol/L, both slightly above optimal targets
- FHx DM (Z83.3): Younger brother recently diagnosed

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:
- Continue metformin and ramipril as prescribed
- Reinforce dietary modifications including high-fibre, low-glycemic foods, avoidance of sugary drinks, and sodium intake limited to approximately 1 teaspoon per day
- Educate on reading food labels and selecting low-sodium options
- Encourage regular physical activity: continue walking and add light strength training twice weekly if possible
- Refer to dietitian for individualized nutrition counseling
- Advise home blood glucose monitoring three times per week with log maintenance for review at next visit
- Repeat laboratory investigations in 3 months
- Discuss importance of controlling A1c, blood pressure, and LDL to reduce risk of cardiovascular and renal complications