Diabetes and hypertension follow-up

Clinical note

Diabetes and hypertension follow-up

CC: 3-month follow-up, established patient.
HPI: 58 y/o with type 2 diabetes, hypertension and hyperlipidemia. Home glucose 120-150 fasting. No hypoglycemia. BP at home 130s/80s. Taking metformin, lisinopril, atorvastatin without side effects. Denies chest pain, polyuria, foot ulcers.
Exam: BP 134/82, BMI 31. Feet: monofilament intact bilaterally, no lesions.
A/P: 1. Type 2 diabetes without complications, at goal, continue metformin, A1c today. 2. Hypertension, controlled, continue lisinopril. 3. Hyperlipidemia, continue atorvastatin, lipid panel. Blood drawn in clinic by venipuncture. RTC 3 months.
MDM: moderate (three chronic illnesses, prescription drug management).