Orthopedic New Patient Consult Letter

History of present illness:  
Mr. Robert 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 by eating better and increasing physical activity, specifically walking more. He denies any medication side effects. He monitors his blood glucose at home approximately three times per week, usually in the morning.

Medical/Surgical History:  
- Type 2 diabetes mellitus  
- Hypertension  

Medications:  
- Metformin  
- Ramipril  
- Medication profile is available on the Regional Drug Information System  

Social/Occupational History and Functional Inquiry:  
- The patient's younger brother was recently diagnosed with diabetes.  
- The patient denies any known drug allergies.  

Physical Examination:  
- Blood pressure is 138/84 mmHg. Weight is 84 kg. BMI is 28.3.  
- Cardiac examination reveals normal heart sounds. Pulmonary examination reveals clear lungs. There is no ankle swelling. Abdominal examination reveals a soft, non-tender abdomen. Foot examination reveals intact sensation with no ulcers or skin issues.  

Investigations:  
- Fasting glucose is 7.8 mmol/L. Recent HbA1c is 7.2%. LDL cholesterol is 2.4 mmol/L. Triglycerides are 1.8 mmol/L.  

Assessment & Plan:  

1. Type 2 diabetes mellitus without complications (E11.9)  
- Continue current medications: metformin and ramipril.  
- Refer to dietitian for personalized dietary guidance.  
- Advise patient to focus on high-fibre, low-glycemic foods, avoid sugary drinks, and reduce sodium intake to about 1 teaspoon per day, including from processed foods.  
- Encourage continued walking and recommend adding light strength training twice per week.  
- Advise patient to read food labels and choose low sodium or no added salt options, and to use herbs for flavoring instead of salt.  
- Instruct patient to keep a log of home blood glucose readings and bring it to the next visit.  
- Repeat laboratory tests in 3 months.  

2. Essential (primary) hypertension (I10)  

3. Other hyperlipidemia (E78.49)