Clinic Notes

Presenting Complaints: Patient presents today with complaints of increased fatigue, weight gain, and increased thirst over the past three months. She reports feeling constantly tired, even after adequate sleep. She has gained approximately 10 pounds despite no changes in diet or exercise. She also reports increased thirst and frequent urination. Past Medical: Patient has a history of hypertension, diagnosed five years ago, well-controlled with medication. No prior history of diabetes or thyroid disorders. Medications: * Lisinopril 20mg daily for hypertension. Family History: Mother has a history of type 2 diabetes. Father has a history of hypertension and hypercholesterolemia. Social History: Patient is a non-smoker and drinks alcohol occasionally. She works as a teacher and reports a relatively sedentary lifestyle. She lives with her husband and two children. Diet and Activity: Patient reports a diet high in processed foods and limited physical activity. She has been advised to increase her intake of fruits, vegetables, and lean protein, and to engage in at least 30 minutes of moderate-intensity exercise most days of the week. Examination Findings: * Vital Signs: Blood pressure 140/90 mmHg, heart rate 88 bpm, BMI 32 kg/m². * General: Obese, appears tired. * Thyroid: No palpable nodules or tenderness. Investigations: * Fasting blood glucose * HbA1c * TSH * Free T4 Issues: * Possible pre-diabetes or type 2 diabetes (ICD-10: E11.9) * Hypertension (ICD-10: I10) Plan: * Order fasting blood glucose, HbA1c, TSH, and Free T4 to evaluate for diabetes and thyroid function. * Discuss lifestyle modifications including diet and exercise. * Schedule follow-up appointment in 4 weeks to review lab results and assess response to lifestyle changes. * Provide patient education on diabetes and pre-diabetes.