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).
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.
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%.
- Continue current medications — Metformin 500mg BD, Amlodipine 5mg OD
- Discuss statin initiation at next review given QRISK3 >10% — patient wishes to focus on lifestyle modification first
- Repeat bloods in 6 months: HbA1c, U&Es, lipid profile, ACR
- Diabetic eye screening — confirmed up to date (Oct 2025, no retinopathy)
- Encouraged continued exercise, aim 150 min/week moderate activity. Dietary advice reinforced.
| Drug | Dose | Qty | Status |
|---|---|---|---|
| Metformin 500mg tablets | 1 tab BD | 56 | Active |
| Amlodipine 5mg tablets | 1 tab OD | 28 | Active |
44054006 — Type 2 diabetes mellitus
271000000 — HbA1c measurement
163030003 — Blood pressure reading
401191002 — Diabetic foot examination
38341003 — Essential hypertension