Consultation Timeline
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13/02/2026
Dr. J Patterson
Diabetes Annual Review
Annual diabetic review. HbA1c stable at 52. BP well controlled. Foot exam NAD. Discussed diet and exercise goals for coming year.
Annual Review
28/01/2026
Dr. R Williams
Knee Pain
R knee pain worsening over past 3 weeks. Stiffness AM ~30min. OA knee — Ibuprofen PRN, physio referral discussed.
Acute
15/01/2026
Nurse S Brown
BP Check
Routine BP monitoring. 128/78 — well controlled on Amlodipine 5mg. Repeat in 6 months.
Routine
02/12/2025
Dr. J Patterson
Medication Review
Routine medication review. All three medications reviewed and continued. No side effects reported. Compliance good.
Med Review
18/11/2025
Dr. R Williams
URTI
3-day history of sore throat, cough and rhinorrhoea. No fever. Tonsils — mild erythema, no exudate. Self-care advice given.
Acute
05/11/2025
Nurse S Brown
Flu Vaccination
Seasonal influenza vaccination administered. Batch: FLU2025-4821. L deltoid. No immediate adverse reaction. Advised re common side effects.
Vaccination
Consultation
Medications Issued
Investigations
Referrals
Codes
Diabetes Annual Review Dr. J Patterson · 13/02/2026 14:10 · Face-to-face
History

Patient attends for annual diabetic review. Reports good compliance with Metformin 500mg BD. No episodes of hypoglycaemia. No polyuria or polydipsia. Diet generally good — has reduced sugar intake. Walking 30 minutes 3x/week. No visual changes. No foot symptoms — no numbness, tingling or ulceration. Reports occasional right knee pain (managed separately).

Examination

Vitals: BP 132/82 mmHg HR 72 bpm BMI 28.4 kg/m² Weight 76.2 kg

Foot examination: Peripheral pulses palpable bilaterally. Monofilament sensation intact 10/10 sites. No calluses, ulceration or deformity. Skin intact. Nails well maintained.

Assessment

Type 2 diabetes mellitus — well controlled. HbA1c 52 mmol/mol (target <58). Stable from previous 54 mmol/mol (Aug 2025).

Hypertension — controlled. BP at target on Amlodipine 5mg OD.

Renal function: eGFR 78 mL/min (stable). ACR 1.8 mg/mmol (normal). Lipids: Total cholesterol 5.2 mmol/L, HDL 1.4 mmol/L. QRISK3 score 11.2%.

Plan

1. Continue current medications — Metformin 500mg BD, Amlodipine 5mg OD
2. Discuss statin initiation at next review given QRISK3 >10% — patient wishes to focus on lifestyle modification first
3. Repeat bloods in 6 months: HbA1c, U&Es, lipid profile, ACR
4. Diabetic eye screening — confirmed up to date (Oct 2025, no retinopathy)
5. Encouraged continued exercise, aim 150 min/week moderate activity. Dietary advice reinforced.

Medications Issued

Drug | Dose | Qty | Status
--- | --- | --- | ---
Metformin 500mg tablets | 1 tab BD | 56 | Active
Amlodipine 5mg tablets | 1 tab OD | 28 | Active

SNOMED CT Codes
314772004 — Diabetes mellitus annual review
44054006 — Type 2 diabetes mellitus
271000000 — HbA1c measurement
163030003 — Blood pressure reading
401191002 — Diabetic foot examination
38341003 — Essential hypertension
Active Problems 3
Type 2 Diabetes Mellitus
Diagnosed 2019 · Active
Essential Hypertension
Diagnosed 2015 · Active
OA Right Knee
Diagnosed 2021 · Active
Medications 3
Metformin 500mg tablets
1 tab BD
Repeat · 56 tabs
Amlodipine 5mg tablets
1 tab OD
Repeat · 28 tabs
Ibuprofen 400mg tablets
1 tab PRN
Acute · 24 tabs
Recent Results 3
HbA1c
10/02/2026
52
eGFR
10/02/2026
78
Total Cholesterol
10/02/2026
5.2
Allergies 1
PENICILLIN
Reaction: Rash
Moderate
Riverside Medical Centre Dr. J Patterson 13/02/2026 14:35
Record: Read/Write