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Clinical Note

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Sample note (editable)

Patient: 62-year-old female presenting for annual wellness visit.

Chief Complaint: Annual exam, medication refills, and follow-up on chronic conditions.

History of Present Illness:
Patient reports generally feeling well. She has been compliant with her hypertension and diabetes medications. Blood pressure readings at home have been averaging 138/84. She checks her blood glucose daily, fasting levels ranging 110-140 mg/dL. She reports occasional numbness in her feet, worse at night. She denies chest pain, shortness of breath, or visual changes. She has gained 5 lbs since last visit. She walks 20 minutes 3 times per week.

Past Medical History:
- Type 2 Diabetes Mellitus (diagnosed 2018)
- Essential Hypertension (diagnosed 2015)
- Hyperlipidemia
- Obesity (BMI 32.4)
- Peripheral neuropathy

Current Medications:
- Metformin 1000mg BID
- Lisinopril 20mg daily
- Atorvastatin 40mg daily
- Gabapentin 300mg TID

Review of Systems:
Constitutional: No fever, fatigue, or unintended weight loss
HEENT: No vision changes, no hearing loss
Cardiovascular: No chest pain, no palpitations
Respiratory: No shortness of breath, no cough
GI: No abdominal pain, regular bowel movements
Endocrine: Increased thirst noted, no heat/cold intolerance
Neurologic: Numbness and tingling bilateral feet
Musculoskeletal: Mild bilateral knee pain with activity

Physical Exam:
Vitals: BP 142/86, HR 78, RR 16, Temp 98.4F, SpO2 98%, BMI 32.4
General: Alert, oriented, in no acute distress
HEENT: PERRLA, TMs clear, oropharynx normal
Neck: No thyromegaly, no JVD
Heart: RRR, no murmurs, gallops, or rubs
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, no hepatosplenomegaly
Extremities: No edema, decreased monofilament sensation bilateral feet
Skin: No concerning lesions

Labs (drawn 3 days ago):
HbA1c: 7.8% (up from 7.2% 6 months ago)
Fasting glucose: 148 mg/dL
LDL: 98 mg/dL
HDL: 42 mg/dL
Triglycerides: 188 mg/dL
Creatinine: 1.1 mg/dL
eGFR: 68 mL/min
Urine microalbumin/creatinine ratio: 45 mg/g

Assessment: Uncontrolled diabetes with worsening A1c, hypertension at goal but borderline, diabetic peripheral neuropathy stable, hyperlipidemia controlled on statin. Early diabetic nephropathy suggested by microalbuminuria and declining eGFR.

Plan: Increase metformin to 1000mg BID with addition of empagliflozin 10mg daily for cardio-renal protection. Continue lisinopril, consider increasing to 40mg if next BP elevated. Continue atorvastatin. Refer to podiatry for diabetic foot exam. Refer to dietitian. Recheck HbA1c in 3 months. Annual diabetic eye exam ordered.

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