Skin Lesion Assessment and Full Skin Examination (FSE) Note Template

Subjective:
SUBJECTIVE and HPI:
Michael presents for follow-up of diabetes and hypertension management. He reports that he has been trying to keep his blood glucose and blood pressure under control, with efforts to improve his diet and increase physical activity, specifically walking. He confirms adherence to his prescribed medications, metformin and ramipril, and denies experiencing any side effects from these medications. Michael reports no known allergies. He mentions a recent change in family history, stating that his younger brother was recently diagnosed with diabetes.

Assessment:
Michael is being managed for type 2 diabetes mellitus and hypertension. His fasting glucose is 7.8 mmol/L and his most recent hemoglobin A1c is 7.2%, which is stable but above the target of less than 7%. His blood pressure today is 138/84 mmHg, which is slightly elevated but improved compared to the previous visit. His low-density lipoprotein cholesterol is 2.4 mmol/L and triglycerides are 1.8 mmol/L, both slightly above optimal targets. There is no ankle swelling and no abdominal tenderness noted on examination.

Plan:
Discussed with Michael the importance of long-term control of blood glucose, blood pressure, and cholesterol to reduce the risk of cardiovascular and renal complications. Provided dietary advice emphasizing high-fibre, low-glycemic foods, avoidance of sugary drinks, and reduction of sodium intake to approximately one teaspoon per day, including processed and restaurant foods. Encouraged continuation of regular walking and suggested adding light strength training twice weekly. Advised reading food labels for sodium content and using herbs for flavor instead of salt. Recommended keeping a home blood glucose log and bringing it to the next visit. Referral to a dietitian for personalized dietary guidance was made. Plan to repeat laboratory investigations in three months. Reinforced the need for ongoing lifestyle modifications and regular follow-up.