Presenting complains: Follow-Up Visit (Type 2 Diabetes Mellitus)
Patient Information:
• Name: Ahmed, Age: 54 years, Marital Status: Married,
• Occupation: retired teacher
Chief Complaint:
The patient returns for a routine follow-up of type 2 diabetes mellitus. He reports no
new or concerning symptoms and has been feeling generally well.
History of Present Illness:
• Diagnosis of Type 2 Diabetes: Diagnosed with type 2 diabetes mellitus 6
years ago. The patient was initially symptomatic with polyuria, polydipsia,
and fatigue but has had stable glucose control since starting treatment.
• Current Status: The patient reports good overall control of his blood sugar
with no hypoglycemic episodes or significant changes in weight. He adheres
to his prescribed diabetes medications and dietary recommendations.
• Symptoms: No new symptoms such as increased thirst, frequent urination,
blurred vision, or fatigue. The patient denies numbness or tingling in
extremities, which was a concern during previous visits. There is no chest
pain, dizziness, or shortness of breath.
• Recent Glucose Levels: The patient reports regularly checking his blood
glucose levels at home, with fasting blood glucose consistently ranging from
5 to 6 mg/dL. The patient also reports post-meal blood glucose values within
target range.
Past Medical History:
• Type 2 Diabetes Mellitus: Diagnosed 6 years ago, with stable control since
initiation of treatment.
• No Other Known Comorbidities: The patient has no history of hypertension,
hyperlipidemia, cardiovascular disease, stroke, chronic kidney disease, or
liver disease. No history of hospitalization or surgeries.
• Medications: Metformin 1000 mg twice daily (no dose adjustments recently)
• Allergies: No known drug allergies or environmental allergies.
Family History:
• Diabetes Mellitus: Positive family history of type 2 diabetes. Father was
diagnosed at age 50 and has been managed with oral medications. Mother
has no diabetes history.
• Cardiovascular Disease: Father had a history of hypertension, but no known
heart disease. No significant family history of stroke or myocardial infarction.
• Other Relevant Family History: No family history of cancer, chronic kidney
disease, or other genetic conditions.
Social History:
• Diet: The patient follows a relatively healthy diet, emphasizing whole grains,
lean proteins, vegetables, and fruits. He avoids sugary snacks and is mindful
of portion sizes, especially carbohydrates. He reports adhering to a diabetic-
friendly meal plan.
• Exercise: The patient has been able to incorporate physical activity into his
routine. He participates in [e.g., 30 minutes of brisk walking, cycling, or
swimming] at least 4 times a week, which has helped with weight
management and energy levels.
• Alcohol Consumption: denies alcohol consumption
• Smoking: The patient is a non-smoker and has never smoked.
• Sleep: The patient reports an adequate sleep pattern, averaging 7-8 hours of
sleep per night. No complaints of sleep apnea or insomnia.
Review of Systems:
• General: No weight loss, no fatigue, and no generalized malaise.
• Endocrine: The patient reports no increased thirst or frequent urination. No
history of hypoglycemia.
• Cardiovascular: No chest pain, palpitations, or shortness of breath.
• Respiratory: No cough or wheezing.
• Gastrointestinal: No abdominal pain, nausea, vomiting, or changes in bowel
habits.
• Neurological: No dizziness, weakness, or numbness. No history of diabetic
neuropathy.
• Musculoskeletal: No joint pain or stiffness.
• Skin: No rashes, wounds, or diabetic ulcers. Skin turgor is normal.
• Urinary: No dysuria, frequency, or hematuria.
ICE: what is your idea regarding to your state? is there anything concern you?, What
are your expectations or goals regarding your treatment moving forward?
