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Date: 2026-02-20

OFFICE VISIT - FOLLOW UP

Chief Complaint: Follow-up for Type 2 Diabetes and Hypertension

History of Present Illness:
Patient presents for routine follow-up. Reports good medication compliance but has been experiencing occasional headaches. Blood glucose readings at home have been ranging 180-220 mg/dL, which is above target. Patient missed last ophthalmology referral appointment. Mentions lab work was done at an outside facility last month but results have not been received.

Assessment and Plan:

1. Type 2 Diabetes - poorly controlled
   - Hemoglobin A1c was 8.2% last check in November. We need to recheck A1c in 3 weeks to assess trajectory before adjusting medications.
   - Continue metformin 1000mg BID
   - Refer to diabetes educator

2. Hypertension - stable
   - BP today 142/88, slightly elevated
   - Recheck potassium and basic metabolic panel in 2 weeks given recent lisinopril dose increase
   - Return to clinic in 6 weeks for BP recheck

3. Preventive Care
   - Patient is overdue for follow-up CT chest given history of pulmonary nodule found incidentally last year. Please schedule repeat CT chest within the next 4 weeks.
   - Need to obtain outside lab records from Quest Diagnostics from January visit

Follow-up: Return in 6 weeks. Sooner if symptoms worsen.

Signed: Dr. Sarah Chen, MD

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