Active Problems
Type 2 Diabetes Mellitus
Hypertension
OA Right Knee
Current Medications
Metformin 500mg
BD · Oral
Amlodipine 5mg
OD · Oral
Ibuprofen 400mg
PRN · Oral
Allergies
Penicillin
— Rash
Latest Values
BP
138/8213/02
HbA1c
5207/02
eGFR
7807/02
Chol
5.207/02
Weight
74.2kg13/02
BMI
27.413/02
Care Due
BP re-check Mar 2026
Annual bloods Aug 2026
Foot check Feb 2027
Cervical screen May 2026
Patient Timeline
13/02/2026
Consultation
Diabetes Annual Review
Dr Patterson. HbA1c 52 mmol/mol, BP 138/82. Reviewed medications, diet and exercise. Foot exam normal.
07/02/2026
Result
Blood Tests
HbA1c 52 mmol/mol, eGFR 78 mL/min, Total Cholesterol 5.2 mmol/L. All within acceptable range.
28/01/2026
Consultation
Knee Pain Review
Dr Williams. Right knee pain ongoing. X-ray confirms moderate OA changes. Discussed physio and weight management.
15/01/2026
Consultation
BP Check
Nurse Brown. BP 142/86 — slightly above target. Advised dietary salt reduction. Re-check in 4 weeks.
10/01/2026
Result
X-Ray Right Knee
Moderate osteoarthritic changes in right knee. Joint space narrowing. No fracture or effusion.
02/12/2025
Consultation
Medication Review
Dr Patterson. Routine medication review. All medications well tolerated. No changes required. Continue current regime.
02/12/2025
Prescription
Repeat Prescription Issued
Metformin 500mg tablets x56, Amlodipine 5mg tablets x28. Repeat authorised by Dr Patterson.
18/11/2025
Consultation
URTI
Dr Williams. Upper respiratory tract infection, 4-day history. No chest signs. Symptomatic relief advised.
05/11/2025
Immunisation
Influenza Vaccine 2025/26
Seasonal influenza vaccination administered. Nurse Brown. Batch: FLU25-8891. Left deltoid. No adverse reaction.
18/10/2025
Immunisation
COVID-19 Booster
COVID-19 autumn booster administered. Nurse Brown. Batch: COV25-4421. Right deltoid. No adverse reaction.
14/10/2025
Consultation
Chest Infection
Dr Patterson. Productive cough 7 days, green sputum. Crackles left base. Doxycycline prescribed. Review if not improving.
14/10/2025
Prescription
Acute Prescription
Doxycycline 200mg capsules x5. Acute issue. One daily for 5 days. Penicillin allergy — alternative antibiotic.
Consultation
13 February 2026 · 09:40
Diabetes Annual Review
Clinician: Dr. J Patterson · Oakfield Surgery
History
Annual diabetic review. Patient reports generally well-controlled blood sugars with home monitoring. No episodes of hypoglycaemia. Diet remains good with regular walking 3–4 times per week. No polyuria, polydipsia or unexplained weight change. Reports occasional right knee pain limiting longer walks, managed with PRN ibuprofen. No foot problems, no visual changes.
Examination
BP
138/82 mmHg
Weight
74.2 kg
BMI
27.4
HbA1c
52 mmol/mol
Foot Exam
Normal pulses
Sensation
Intact bilat.
Assessment
- Type 2 diabetes — reasonable control, HbA1c 52 within NICE target (<53 for monotherapy). No microvascular complications identified on today’s review.
- Hypertension — BP marginally above target at 138/82. Recent readings variable (142/86 on 15/01). Continue to monitor; consider dose adjustment if persistently above 140/90.
- Osteoarthritis right knee — stable, managing with activity modification and PRN ibuprofen. Mindful of renal function with regular NSAID use (eGFR 78).
Plan
- Continue Metformin 500mg BD — well tolerated, good glycaemic control
- Continue Amlodipine 5mg OD — recheck BP in 4–6 weeks; if >140/90 consider uptitrating to 10mg
- Counsel re: ibuprofen use with eGFR 78 — avoid prolonged courses, consider paracetamol as alternative
- Repeat bloods in 6 months (HbA1c, U&E, lipids, LFT)
- Diabetic retinal screening — confirm attendance for next scheduled appointment
- Foot review in 12 months unless new symptoms. Patient to report any numbness, tingling or skin changes
Clinical Codes
C10E. Type 2 diabetes mellitus
XaJQp Diabetes annual review
XaJ4b HbA1c level
246.. O/E - blood pressure
22K.. Body mass index