Sports Medicine / Orthopedic Consult

Dear: Mr. Thomas

Mr. Thomas presented for a follow-up visit regarding his type 2 diabetes mellitus and hypertension. The consultation was conducted on February 7, 2026.

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. He denies any medication side effects and monitors his blood glucose at home approximately three times per week, usually in the morning. There are no new symptoms reported.

SUMMARY:
Current Condition/Complaint:
- Follow-up for type 2 diabetes mellitus and hypertension
- No new symptoms reported
- Patient has been adhering to medication regimen and lifestyle modifications

The patient’s current diagnosis includes type 2 diabetes mellitus without complications, essential (primary) hypertension, and other hyperlipidemia. He is currently treated with metformin and ramipril daily without side effects. Laboratory results show a fasting glucose of 7.8 mmol/L, HbA1c of 7.2%, LDL cholesterol of 2.4 mmol/L, and triglycerides of 1.8 mmol/L. Blood pressure today was 138/84 mmHg, weight 84 kg, and BMI 28.3.

IMPRESSION:
- Stable type 2 diabetes mellitus and hypertension with no complications
- Lipid profile slightly elevated but manageable
- Patient is compliant with medications and lifestyle changes
- Continued focus on controlling A1c, blood pressure, and LDL to target values is important to reduce cardiovascular and renal risk

DIAGNOSIS:
- E11.9 - Type 2 diabetes mellitus without complications
- I10 - Essential (primary) hypertension
- E78.49 - Other hyperlipidemia

PLAN:
- Continue current regimen of metformin and ramipril
- Refer to dietitian for personalized dietary guidance
- Advise patient to maintain a high-fibre, low-glycemic diet, avoid sugary drinks, and reduce sodium intake to approximately 1 teaspoon per day, including processed foods
- Encourage continuation of regular walking and recommend adding light strength training twice weekly
- Instruct patient to keep a log of home blood glucose readings and bring it to the next visit
- Repeat laboratory tests in 3 months
- Reinforce importance of controlling A1c, blood pressure, and LDL to target values to reduce cardiovascular and renal risk

1. Type 2 diabetes mellitus
- Stable diabetes management
- Continue current medications and lifestyle modifications
- Monitor blood glucose regularly

2. Hypertension
- Controlled blood pressure with current therapy
- Continue ramipril and lifestyle changes
- Monitor blood pressure regularly

3. Hyperlipidemia
- Mildly elevated LDL and triglycerides
- Dietary modifications recommended
- Monitor lipid profile on follow-up

Please contact the clinic if you have any questions or concerns.