IM/Hospitalist New Patient Consult Template September 2025 Narrative Version

Past Medical History:
- Type 2 diabetes mellitus
- Hypertension

Family History:
- Younger brother recently diagnosed with diabetes

Allergies:
- No known drug allergies

Medications:
- Metformin daily
- Ramipril daily

Physical Examination:
- Blood pressure 138/84 mmHg
- Weight 84 kg, BMI 28.3
- Cardiac examination: normal heart sounds
- Pulmonary examination: clear lungs
- No ankle swelling
- Abdomen: soft, non-tender
- Foot examination: intact sensation, no ulcers or skin issues

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. Robert presents for follow-up of type 2 diabetes mellitus and hypertension. His blood pressure and glycemic control are fairly stable but slightly above ideal targets. Lipid profile shows mild hyperlipidemia. Physical examination is unremarkable with no signs of complications.

Assessment & Plan
1. Type 2 diabetes mellitus
- Continue metformin therapy
- Advise high-fiber, low-glycemic diet and avoidance of sugary drinks
- Encourage regular walking and add light strength training twice weekly
- Refer to dietitian for personalized dietary guidance
- Instruct patient to keep a log of home blood glucose readings and bring to next visit
- Repeat laboratory tests in 3 months

2. Essential hypertension
- Continue ramipril therapy
- Advise sodium intake reduction to approximately 1 teaspoon per day including processed and restaurant foods
- Monitor blood pressure regularly

3. Other hyperlipidemia
- Lifestyle modification as above to improve lipid profile

SHORT SUMMARY:
Mr. Robert was seen for follow-up of his diabetes and hypertension management. His blood pressure and blood glucose levels are fairly stable but above ideal targets. He is compliant with medications and reports no side effects. He was counseled on diet, exercise, and sodium restriction, and referred to a dietitian for further guidance. Repeat labs are planned in 3 months.