IM/Hospitalist New Patient Consult Template September 2025

History:
- Mr. David presents for follow-up of type 2 diabetes mellitus and hypertension. He reports that he has been trying to keep his blood sugars and blood pressure under control. He has made efforts to improve his diet and increase physical activity, specifically by walking more. He denies any medication side effects.
- The patient's younger brother was recently diagnosed with diabetes.

Past Medical History:
- The patient has a history of type 2 diabetes mellitus and hypertension.

Family History:
- The patient's younger brother was recently diagnosed with diabetes.

Medications:
- Metformin daily
- Ramipril daily

Physical Examination:
- Blood pressure is 138/84 mmHg.
- Weight is 84 kg.
- BMI is 28.3.
- Cardiovascular: Heart sounds are normal.
- Respiratory: Lungs are clear to auscultation.
- Extremities: No ankle swelling observed.
- Abdomen: Abdomen is soft and non-tender.
- Neurological: Foot sensation is intact.
- Dermatological: No ulcers or skin issues on feet.

Investigations:
LABS:
Fasting glucose: 7.8 mmol/L
HbA1c: 7.2%
LDL cholesterol: 2.4 mmol/L
Triglycerides: 1.8 mmol/L

Clinical Impression:
Mr. David is a patient with type 2 diabetes mellitus and essential hypertension who is maintaining relatively stable blood glucose and blood pressure levels with current therapy. His HbA1c is slightly above target, and lipid profile shows mildly elevated LDL and triglycerides. Physical examination reveals no acute complications or signs of end-organ damage. Continued management and lifestyle modifications are essential to reduce cardiovascular and renal risks.

Assessment & Plan:
1. Type 2 diabetes mellitus
- Continue current medications: metformin.
- Advise patient to maintain a high-fiber, low-glycemic diet, avoid sugary drinks.
- Encourage continued physical activity, including walking and addition of light strength training twice weekly if possible.
- Instruct patient to monitor blood glucose at home and keep a log to bring to next visit.
- Repeat laboratory tests in 3 months.
- Refer to dietitian for personalized dietary guidance.

2. Essential hypertension
- Continue current medication: ramipril.
- Advise patient to reduce sodium intake to approximately 1 teaspoon per day.
- Reinforce importance of controlling blood pressure to reduce cardiovascular and renal risk.

3. Other hyperlipidemia
- Monitor lipid profile and reinforce lifestyle modifications.

4. Overweight
- Encourage weight management through diet and exercise.

SHORT SUMMARY:
Mr. David presented for follow-up of his type 2 diabetes mellitus and hypertension. His blood pressure and blood glucose levels are fairly stable with current medications, though targets have not been fully achieved. He has been advised on dietary modifications, physical activity, and home glucose monitoring. A referral to a dietitian was made, and labs will be repeated in 3 months.