HH PHA F/U Apt

Plan:
PHA MD Plan::
1) Type 2 diabetes mellitus - Continue metformin as prescribed. Encourage dietary modifications focusing on high-fiber, low-glycemic foods, and avoidance of sugary drinks. Recommend regular physical activity including walking and light strength training. Advise home blood glucose monitoring three times per week and maintain a log. Refer to registered dietitian for further dietary counseling. 2) Essential hypertension - Continue ramipril as prescribed. Advise reduction of sodium intake to approximately one teaspoon per day, including sodium from processed foods and restaurant meals. Encourage reading food labels and using herbs for flavoring instead of salt. 3) Dyslipidemia - Continue current management. Reinforce dietary and lifestyle modifications. 4) Family history - Note of younger brother recently diagnosed with diabetes, reinforcing the importance of risk factor management.

Registered Dietitian (RD) Plan:
Referral to registered dietitian for personalized dietary guidance is initiated.

Follow-up:
1) Diabetes: Repeat laboratory investigations in three months. 2) Hypertension: Monitor blood pressure and continue lifestyle modifications. 3) Dyslipidemia: Continue current management and dietary modifications.

Objective:
General: Robert appears well and in no acute distress. Vitals: Blood pressure is 138/84 millimeters of mercury. Weight is 84 kilograms. Body mass index is 28.3. Fasting glucose is 7.8 millimoles per liter. Hemoglobin A1c is 7.2 percent. Low-density lipoprotein is 2.4 millimoles per liter. Triglycerides are 1.8 millimoles per liter. Heart sounds are normal. Lungs are clear to auscultation. Abdomen is soft with no tenderness. No ankle swelling is present. Foot sensation is intact with no ulcers or skin issues. No medication side effects are reported. No known allergies.

Assessment:
1) Type 2 diabetes mellitus (E11), suboptimally controlled. 2) Essential hypertension (I10), suboptimally controlled. 3) Dyslipidemia (E78.49).

Signature:
Daniel Lee, MD
Regional Medical Center