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- **Date:** March 28, 2024
- **Patient:** Brian Lee, 55 years old
- **MRN:** 00785642
- **Chief Complaint:** "I've been having trouble managing my blood sugar levels."
- **History of Present Illness:** The patient is a 55-year-old with a known diagnosis of Type 2 Diabetes Mellitus, presenting with difficulty in managing blood sugar levels over the past month. Reports fluctuating blood sugar readings despite adherence to prescribed diet and medication. The patient expresses a desire to avoid any complications associated with poor diabetes management.
- **Past Medical History:** Type 2 Diabetes Mellitus, controlled hypertension
- **Social History:**
- The patient is a self-employed graphic designer, working from a home office. They describe their work as fulfilling and report a stable income. They own a home in a well-regarded neighborhood, noting its quiet and safe environment. The patient has a supportive spouse and a close circle of friends, often participating in social gatherings and community events.
- The patient completed a bachelor's degree in graphic design and continues to take online courses to stay updated in their field. They have reliable transportation, a recent model car, ensuring timely access to healthcare appointments. The patient is an active member of a local walking group, which meets thrice a week for exercise and socialization.
- Nutritionally, the patient is mindful of their diet, focusing on low-glycemic foods, and has not faced issues with food security. They have comprehensive health insurance coverage through a private provider, with satisfactory benefits that cover their medical needs, including diabetes management.
- **Review of Systems:** Reports consistent adherence to diabetic diet and medication regimen. Denies any episodes of hypoglycemia or diabetic ketoacidosis.
- **Physical Examination:**
- - General: Well-nourished and well-kept appearance. Alert and oriented.
- - Vitals: BP 130/80, HR 72, Temp 98.6°F, Resp 14/min
- **Assessment/Plan:**
- - Review current diabetes management plan and consider medication adjustments.
- - Recommend continuous glucose monitoring (CGM) to better understand glucose patterns and variability.
- - Encourage continued engagement with community exercise groups and dietary mindfulness.
- - Schedule a follow-up appointment in 3 months or sooner if glucose management issues persist.
- **Comments:** The patient demonstrates a proactive approach to managing their diabetes, supported by a stable and healthy social environment. Continued focus on lifestyle modification and close monitoring of blood sugar levels are key to preventing complications.
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