Medical Note Template

Subjective:
S:
Mr. David presents for follow-up of diabetes and hypertension management. He reports adherence to metformin and ramipril without side effects. He has been making efforts to improve his diet and increase physical activity, specifically walking more. He monitors his blood glucose at home approximately three times per week, usually in the morning. He denies any known drug allergies. He notes a recent change in family history, with his younger brother newly diagnosed with diabetes.

Objective:
O:
Well appearing, no acute distress. Blood pressure 138/84 mmHg. Weight 84 kg. Body mass index 28.3. Heart sounds normal. Lungs clear to auscultation bilaterally. No ankle swelling. Abdomen soft, no tenderness. Foot sensation intact. No foot ulcers or skin issues.

Assessment and Plan:
A/P:
Type 2 diabetes mellitus  
Glycemic control stable but above target. Continue metformin. Reinforce dietary modifications and regular physical activity. Refer to dietitian for further guidance. Repeat laboratory studies in 3 months.

Hypertension  
Blood pressure improved but not at target. Continue ramipril. Advise sodium restriction to approximately 1 teaspoon per day. Encourage home blood pressure monitoring.

Dyslipidemia  
Low-density lipoprotein and triglycerides slightly elevated. Continue current management. Reinforce dietary counseling.

Family history of diabetes  
Discussed increased risk and importance of ongoing risk factor management.