Fam Med Office Visit Note

History of Present Illness: Mr. John Smith is a 67-year-old male with a history of hypertension and type 2 diabetes presenting for a routine check-up. Mr. Smith has been a patient of "Dr. Thomas Kelly" for the past 5 years. He has been compliant with his medications and has been attending his appointments regularly. His last HbA1c was 7.2% three months ago. Hypertension: Mr. Smith was diagnosed with hypertension 10 years ago. He has a family history of hypertension. He takes Lisinopril 20mg once daily. His blood pressure readings at home have been consistently around 130/80 mmHg. His most recent blood pressure reading in the clinic was 132/82 mmHg on 1 November 2024. Type 2 Diabetes: Mr. Smith was diagnosed with type 2 diabetes 5 years ago. He takes Metformin 1000mg twice daily. His last HbA1c was 7.2% three months ago. He monitors his blood sugar levels at home and reports readings within the target range. Other Medications and Supplements: * Aspirin 81mg daily * Vitamin D 1000 IU daily Allergies: * No known drug allergies Social History: Mr. Smith is a retired accountant. He is married and lives with his wife. He does not smoke or drink alcohol. He exercises regularly and maintains a healthy diet. Objective: Vital Signs: * BP: 132/82 mmHg * HR: 72 bpm * Temp: 37°C * RR: 16 breaths/min * SpO2: 98% on room air * Weight: 80 kg * Height: 178 cm * BMI: 25.2 kg/m² Physical Examination: * General: Alert and oriented, appears well. * Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. * Respiratory: Clear to auscultation bilaterally. * Abdomen: Soft, non-tender. * Extremities: No edema. Assessment and Plan: Hypertension * Assessment: Controlled hypertension. * Plan: Continue Lisinopril 20mg daily. Monitor blood pressure at home. Follow up in 3 months. Type 2 Diabetes * Assessment: Controlled type 2 diabetes. * Plan: Continue Metformin 1000mg twice daily. Monitor blood sugar levels at home. Follow up in 3 months. Review HbA1c in 3 months. Additional Recommendations: Encourage Mr. Smith to continue with his healthy lifestyle. Provide education on the importance of regular exercise and a balanced diet. Schedule a flu shot for the upcoming flu season.