Ambulatory Clinic Note

Physician's Ambulatory Clinic Note Chief Complaint: Routine follow-up for chronic hypertension and new concerns regarding persistent fatigue. History of Presenting Illness: Patient, a 58-year-old male with a known history of hypertension and well-controlled type 2 diabetes, presents with a 3-month history of increasing fatigue. The fatigue is described as constant, non-radiating, dull, and significantly impacting his daily activities, including his ability to concentrate at work. He reports no specific provoking factors and states it is worse in the afternoons. He denies any associated chest pain, shortness of breath, fever, or weight changes. He has tried increasing his sleep and reducing caffeine intake without improvement. Past Medical History: Hypertension (diagnosed 10 years ago), Type 2 Diabetes Mellitus (diagnosed 5 years ago), Hyperlipidemia. Home Medications: * Lisinopril 20mg once daily * Metformin 500mg twice daily * Atorvastatin 40mg once daily Allergies: Penicillin (rash) Social History: Married with two adult children. Lives in a house with his wife. Works as an accountant. Reports occasional alcohol consumption (2-3 units per week). Denies tobacco use (quit 15 years ago, previously 10 pack-years) and recreational drug use. Heterosexual, monogamous relationship, uses condoms inconsistently. Income from employment. Has one dog. Family History: Father had hypertension and died of a myocardial infarction at age 65. Mother has Type 2 Diabetes. No known family history of TB, cancer, psychiatric illness, or genetic conditions. Screening: * Colonoscopy (last: 3 years ago, normal) * PSA (last: 1 year ago, normal) * HIV testing (last: 2 years ago, negative) * Diabetes screening (ongoing due to diagnosis) * Hypertension screening (ongoing due to diagnosis) Vaccinations: * COVID-19: 3 doses (last booster 6 months ago) * Influenza: Annually (last 2 months ago) * Pneumococcal: Last received 5 years ago (PCV13), due for PPSV23. * Tetanus/Diphtheria/Pertussis (TdaP): Last received 8 years ago, due for booster. PHQ 9: 5 STEADI Fall Risk: Low Mini-Cog: 4/5 ASCVD score or MESA-CAC Score: 12% (10-year risk) Assessment/Plan: 1. Chronic Fatigue Impression: Patient presents with new onset, persistent fatigue. While initial PHQ-9 is low, further investigation is warranted to rule out underlying organic causes, given the patient's age and comorbidities. Consider iron deficiency, thyroid dysfunction, and sleep disorders. Differential diagnosis: Anaemia, Hypothyroidism, Sleep Apnoea, Depression, medication side effect, chronic viral illness. Investigations planned: Full blood count, Ferritin, Thyroid stimulating hormone (TSH), B12, Folate, Glucose (HbA1c already monitored). Consider sleep study if initial labs are unremarkable. Treatment planned: Patient advised to maintain regular sleep schedule, ensure balanced diet. Will review lab results. Relevant referrals: None at this stage. 2. Hypertension, Essential Primary Impression: Blood pressure well-controlled on current medication. No new concerns. Investigations planned: None. Treatment planned: Continue Lisinopril 20mg daily. Advised lifestyle modifications (diet, exercise). Relevant referrals: None. 3. Type 2 Diabetes Mellitus Impression: Glycaemic control stable with current Metformin. Patient reports good adherence to medication and diet. Investigations planned: HbA1c to be repeated in 3 months. Treatment planned: Continue Metformin 500mg twice daily. Reinforce dietary advice. Relevant referrals: None. Billing Codes: CPT 99213 - Established Patient Office or Other Outpatient Visit, 15-29 minutes ICD-10 R53.83 - Other fatigue ICD-10 I10 - Essential (primary) hypertension ICD-10 E11.9 - Type 2 diabetes mellitus without complications