Patient
62-year-old male, diabetes follow-up at 3 months
Interval History
No hypoglycaemic episodes since the last visit. Walking 30 minutes four days per week and has reduced sugar-sweetened drinks. Reports occasional tingling in both toes, unchanged from last review. No chest pain, exertional dyspnoea, or visual change.
Current Status
Weight 86.4 kg, down 1.8 kg. BP 132/78. Home glucose readings are generally 6.8–8.5 mmol/L before breakfast. Foot examination shows intact skin, palpable pulses, and mildly reduced vibration sense at both great toes. HbA1c is 7.2%, improved from 7.8%.
Changes Since Last Visit
Glycaemic control has improved with activity and dietary changes. Weight is trending down. Distal sensory symptoms remain stable without ulceration or functional limitation. No medication changes or adverse effects reported.
Updated Plan
- Continue metformin 1 g twice daily.
- Continue current activity and dietary changes.
- Reinforce daily foot inspection and well-fitting footwear.
- Repeat HbA1c, renal function, and urine albumin-to-creatinine ratio before the next visit.
- Review in three months, or sooner for worsening numbness, skin breakdown, or symptomatic hypoglycaemia.