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National Colony, Aurangabad, 431001 · Mon - Fri: 9am - 5pm

Report #17 · Office & outpatient

HTN & DM

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Clinical note · #17

Office & outpatient

Patient Name: John Smith

Date of Birth: 12/15/1965

Gender: Male

MRN #: 123456789

Date of Service: 04/07/2024

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Chief Complaint

  • Follow-up for hypertension and type 2 diabetes

History of Present Illness

Mr. Smith is a 58-year-old male presenting for follow-up of his hypertension and type 2 diabetes. He reports good adherence to his medications but admits to occasional missed doses due to forgetfulness. He denies any symptoms of hypoglycemia or hyperglycemia. His last A1C was 7.2%.

Past Medical History

  • Hypertension diagnosed in 2005
  • Type 2 diabetes diagnosed in 2010
  • Hyperlipidemia
  • Osteoarthritis
  • GERD

Medications

  • Lisinopril 20 mg daily for hypertension
  • Metformin 1000 mg twice daily for diabetes
  • Atorvastatin 20 mg daily for hyperlipidemia
  • Omeprazole 20 mg daily for GERD

Allergies

  • No known drug allergies

Social History

  • Non-smoker
  • Occasionally drinks alcohol
  • Retired accountant

Family History

  • Mother had hypertension and type 2 diabetes
  • Father had a history of heart disease

Review of Systems

  • Negative for chest pain, palpitations, shortness of breath, or edema
  • Positive for occasional knee pain and heartburn

Physical Examination

  • General: Well-developed, well-nourished, no acute distress
  • Vital Signs: BP 130/80, HR 72, RR 16, Temp 98.6°F
  • Cardiovascular: Regular rate and rhythm, no murmurs or gallops
  • Abdomen: Soft, non-tender, non-distended, no hepatosplenomegaly

Assessment and Plan

  1. Hypertension: BP goal <130/80 mmHg. Continue lisinopril. Discuss lifestyle modifications.
  2. Type 2 Diabetes: A1C goal <7%. Continue metformin. Reinforce dietary and exercise habits.
  3. Hyperlipidemia: Continue atorvastatin. Monitor lipid panel annually.
  4. GERD: Continue omeprazole. Avoid trigger foods and elevate head of bed.
  5. Knee pain: Recommend over-the-counter analgesics and consider physical therapy if symptoms persist.
  6. Follow-up in 3 months for repeat labs and medication review.

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Electronically signed by [Provider's Name], MD. Date: 04/07/2024. Time: 14:45.