[doctor] good afternoon , beverly . good to see you .
[patient] nice to see you too .
[doctor] so , i know my nurse told you a little bit about dax . um , now , if you do n't mind , i'd like to tell dax a little bit about you .
[patient] go for it .
[doctor] great . um , beverly's a 24 year old female patient , and i know you have a history of type 2 diabetes and high blood pressure . correct ?
[patient] yep .
[doctor] okay . so , you're here today for your yearly exam . have n't seen you in a year . how're you doing ?
[patient] i've been doing well . i began working in a bakery this summer which has been super fun. i have really been enjoying working there, but i find myself, since i am so close to so many delicious treats, snacking a lot during shifts and eating a lot more desserts than i normally would.
[doctor] okay , so , that brings me to your diabetes . so , how have your blood sugars been ?
[patient] uh , not so good .
[doctor] okay .
[patient] so , they've been up and down because of my diet , i think , because i've been taking my medication as prescribed . um , so , i have n't missed anything there , but my diet has been pretty bad lately .
[doctor] pretty bad lately ?
[patient] yeah .
[doctor] okay . and , that's really the only thing that's different is your diet , pretty much ?
[patient] yeah .
[doctor] and , that's because of the new job and all that ?
[patient] yeah. it has been really challenging to resist the temptation. 
[doctor] it's hard to ignore those desserts , are n't they ?
[patient] yeah .
[doctor] no willpower like me ?
[patient] no , no willpower .
[doctor] okay . all right . and , and then , um , i know you've had high blood pressure , hypertension . how is , how have your blood sugars been ? have you been checking them ?
[patient] so , my blood pressure's been good . um , despite my , um , my diabetes levels being up and down .
[doctor] okay .
[patient] so , that's been good .
[doctor] okay , so , your blood pressures have been normal . you've been sleeping well ?
[patient] yep , getting a full eight hours .
[doctor] no concerns about hurting yourself or anything like that ?
[patient] no .

[doctor] okay , good . okay , and i know my , um , nurse did a review of systems . other than what we've talked about so far , is there anything else that you needed to add ?
[patient] no .
[doctor] good . so , pretty much status quo except for those things that we've been working on , right ?
[patient] yep .
[doctor] okay , good . all right . well , let me do a quick physical exam , okay ?
[patient] okay .
[doctor] okay , squeeze my finger here . good . can you feel me touch out here ?
[patient] yep .
[doctor] okay . and , can you feel me touch you down here ?
[patient] yep .
[doctor] okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ?
[patient] yes , i am .
[doctor] okay , and you take that twice a day ?
[patient] yep .
[doctor] okay . um , uh , hey , Sarah ? show me the vital signs . okay , good news here is your blood pressure's good . everything , um , there is fine . so , um , so , my assessment is , is , um , your first problem is diabetes . it's a little out of control . we'd like that hemoglobin a1c to be under seven , um , at least . you know , preferably , under six .
[patient] mm-hmm .
[doctor] so , um , uh , i'm not gon na change your medication . i think this is diet related , so i want you to try to cut down on the snacking and additional sweets , okay ?
[patient] yeah .
[doctor] and , i want you to check your blood sugars in the morning . i want you to call them in in about two weeks so we know what your first , um , fasting blood sugar was in the morning , and then , we'll come back and see you in about two months and see if everything has straightened out . if it has n't , then we'll talk about adding another medication , okay ?
[patient] okay .
[doctor] your second problem is your hypertension . that seems to be relatively stable . i want you to stay on your current medication . you're on li- lisinopril 10 mg once a day . just stay right on that medication . no changes at this point . seems to be doing well , okay ?
[patient] okay .

[doctor] good . anything else i can do for you today ?
[patient] no . that's it .
[doctor] good . come with me , we'll get you checked out .
[patient] thank you .
[doctor] hey , Sarah ? finalize the note .
CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

Beverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.

The patient states she has been doing well. She has recently began working at a bakery this summer.

The patient states her diabetes is uncontrolled. Her blood sugars have fluctuated recently, which she attributes to her change in diet due to work. She is trying to improve her diet by removing additional sweets. She has been taking her medication as prescribed and has not missed any doses.

The patient states her blood pressure has been good despite her blood sugar levels being up and down. She has continued taking metformin twice a day.

She has been sleeping well and is able to sleep a full 8 hours. She denies thoughts of self-harm or suicidal ideations.

PHYSICAL EXAMINATION

• Neurological/Psychological: Grip strength equal bilaterally. Neurologically intact.
• Neck: Supple without thyromegaly or lymphadenopathy. No carotid bruits appreciable.
Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate. Grade 2/6 systolic ejection fraction murmur. No gallops or rubs. No extra heart sounds. Good pulses.

RESULTS

Hemoglobin A1c is elevated.

ASSESSMENT AND PLAN

Beverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.

Diabetes mellitus type 2.
• Medical Reasoning: Her blood glucose levels have been uncontrolled. She is still taking metformin twice a day, but does admit to dietary indiscretion with an increase in her sweets intake.. Her most recent hemoglobin A1c was elevated.
• Medical Treatment: Continue metformin twice a day.
• Patient Education and Counseling: I encouraged her to check her fasting blood glucose levels each morning and call them in about 2 weeks. She will follow up in about 2 months, at which time we will discuss further treatment recommendations.

Hypertension.
• Medical Reasoning: Appears to be relatively stable.
• Medical Treatment: Continue lisinopril 10 mg once daily.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.