General Follow Up

Specialty: Internal Medicine Specialist Past Medical History: - Relevant past medical history: Type 2 Diabetes Mellitus (diagnosed 5 years ago, well-controlled on metformin), Hypertension (diagnosed 10 years ago, managed with lisinopril). - Smoking history: Quit 2 years ago, previously smoked 1 pack per day for 20 years. - Medication adherence: Reports excellent adherence to all prescribed medications. - Allergies: Penicillin (hives). - Recent travel: No recent international travel; visited family in Cornwall last month. Subjective: - Presenting complaint and duration: Follow-up for routine diabetes and hypertension management. Patient reports feeling generally well with no acute concerns. - Additional symptoms: Denies chest pain, shortness of breath, palpitations, dizziness, or peripheral oedema. - Impact on daily activities: No impact on daily activities; maintains regular exercise routine. - Pertinent negatives: No new symptoms of hyperglycaemia or hypoglycaemia. Blood pressure readings at home have been within target range. - Appetite: Good, no significant changes in appetite or weight. - Living situation and sick contacts: Lives with spouse, no sick contacts. - Medications prescribed: Metformin 1000mg twice daily, Lisinopril 20mg once daily. - Diagnostic tests ordered: Recent HbA1c and lipid panel results reviewed. - Specialists referred to: No current referrals to specialists. - Advice to start medications or see specialists: Advised to continue current medications. No new specialist referrals at this time. - Advice regarding laboratory investigations: Advised to repeat routine blood tests (HbA1c, renal function, electrolytes, lipid panel) in 6 months. - Follow-up instructions: Follow up in 6 months for routine review. Social History: - Occupation and hobbies: Retired teacher, enjoys gardening and reading. - Alcohol use and sleep habits: Occasional social alcohol use (1-2 units per week). Reports 7-8 hours of good quality sleep per night. Objective: - Vitals: BP 128/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C, O2 Sat 98% on room air. - Lung exam: Clear to auscultation bilaterally, no wheezes, crackles, or rhonchi. - Cardiac exam: Regular rate and rhythm, S1 S2 present, no murmurs, rubs, or gallops. - Abdominal exam: Soft, non-tender, non-distended, no organomegaly. Assessment: - Primary diagnosis: 1. Type 2 Diabetes Mellitus, well-controlled. 2. Essential Hypertension, well-controlled. Plan: - Diagnostic tests ordered: Repeat HbA1c, renal function, electrolytes, and lipid panel in 6 months. - Medications prescribed: Continue Metformin 1000mg twice daily and Lisinopril 20mg once daily. No changes to current medication regimen. - Inhaler optimisation and technique education: Not applicable. - Follow-up instructions: Schedule follow-up appointment in 6 months for routine review of chronic conditions. - Return precautions: Advised to return sooner if experiencing any acute symptoms such as chest pain, severe headache, vision changes, or signs of infection. - Medication adherence counselling: Reinforced importance of continued adherence to medication for optimal blood glucose and blood pressure control. - Preventative measures discussion: Discussed maintaining healthy diet and regular exercise. Recommended annual flu vaccination and pneumonia vaccination as per guidelines. - Deferral of non-urgent issues: No non-urgent issues identified for deferral. Notes for nursing staff: - Advise patient to book blood tests for 6 months time and to schedule follow-up appointment with Dr. Thomas Kelly.