Scribe BC - BG Followup

Scribe BC - BG Followup **REASON FOR VISIT:** The patient presents today for a routine follow-up to manage their type 2 diabetes. **INTERIM HISTORY:** The patient reports stable blood sugars over the past three months, with an average glucose reading of 145 mg/dL. They are using a continuous glucose monitor (CGM) and report no significant hypoglycemic events. The patient denies any new microvascular or macrovascular complications. **PAST MEDICAL HISTORY:** * Type 2 Diabetes Mellitus * Hypertension * Hyperlipidemia **MEDICATIONS:** * Metformin 1000mg twice daily * Lisinopril 20mg daily * Atorvastatin 40mg daily **ALLERGIES:** * NKDA **PHYSICAL EXAMINATION:** * BMI: 32 kg/m² * Blood pressure: 130/80 mmHg * Fundoscopic exam: no signs of diabetic retinopathy * Foot exam: intact sensation, no ulcers **INVESTIGATIONS:** * HbA1c: 7.2% (October 28, 2024) * Lipid panel: within normal limits (October 28, 2024) * Urine microalbumin: negative (October 28, 2024) **IMPRESSION:** * Type 2 Diabetes Mellitus, well-managed * Hypertension, controlled * Hyperlipidemia, controlled **PLAN:** * Continue current medication regimen. * Encourage patient to maintain current diet and exercise routine. * Review CGM data and provide guidance on glucose management. * Discuss potential risks and side effects of medications. * Schedule annual eye exam and foot exam. **FOLLOW-UP:** * Follow-up appointment in three months to review HbA1c and assess overall diabetes management. "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."