Return Patient Visit

Patient returns for T2DM follow-up. Reports improved energy levels since last visit. Checking blood glucose 2-3x weekly: fasting readings mostly 110-140 mg/dL. Denies polyuria, polydipsia, blurred vision, or numbness/tingling in extremities. No hypoglycemic episodes.

- Started daily 20-min walks after dinner (adherent)

- Reduced sugary beverage intake significantly

- Lost 4 lbs since last visit (current BMI 29.8, down from 30.4)

Metformin 1000 mg BID (tolerating well, no GI side effects currently)

Rosuvastatin 10 mg daily

Lisinopril 10 mg daily

All medications confirmed current and taken as prescribed.

BP 128/82 (improved from 142/88 at last visit)

HR 72, RR 16, Weight 174 lb (-4 lbs)

BMI 29.8

HbA1c: 7.2% (down from 8.4% at last visit)

Fasting glucose: 118 mg/dL

Lipid panel: Total 185, LDL 89 (down from 107), HDL 52, TG 122

BMP: Na 140, K 4.2, Cr 0.9, eGFR >60 — all WNL

Intact sensation to monofilament. No ulcers, calluses, or deformities. Pulses 2+ dorsalis pedis and posterior tibial bilaterally.

T2DM — improving. HbA1c goal <7.0 approached.

1. Continue metformin 1000 mg BID — effective and well-tolerated

2. Continue rosuvastatin 10 mg — LDL now at goal (<100)

3. Continue lisopril 10 mg — BP at goal

4. Lifestyle: maintain walking routine, continue dietary modifications

5. Retinal eye exam referral (due annually per ADA guidelines)

6. Return in 3 months — repeat HbA1c, lipid panel, BMP