LA

Lim Ah Meng

MRN S1234567A · 67M · 12 Aug 1956
Allergy: NKDANo Resuscitation
Encounter
In Progress

Patient Summary

Problems

  • Type 2 Diabetes MellitusE11.9
  • HypertensionI10
  • HyperlipidaemiaE78.5

Medications (6)

  • Metformin 1g BD
  • Amlodipine 5mg OD
  • Perindopril 5mg ON
  • Atorvastatin 20mg ON
  • Aspirin 100mg OD
  • Vitamin D 1000IU OD

Latest Vitals

(24 May 2024)
BP
128/76 mmHg
HR
72 bpm
Temp
36.7 °C
SpO₂
98% (RA)
Weight
72 kg
BMI
24.9 kg/m²

Latest Labs

(15 May 2024)
HbA1c
7.8%
eGFR
89 mL/min/1.73m²
Creatinine
78 umol/L
TC/HDL/LDL
4.1 / 1.2 / 2.2

Recent Encounters

  • 12 May 2024
    OPD – Follow Up
  • 15 Mar 2024
    Discharge Summary
  • 10 Feb 2024
    OPD – Review
1

Quick Clinical Input (type shorthand or key points)

2

AI Generated SOAP Note (review and edit)

Patient seen for follow-up of type 2 diabetes mellitus and hypertension.

  • Reports fasting blood glucose at home ranging 7–9 mmol/L.
  • No hypoglycaemic episodes.
  • No chest pain, no shortness of breath, no dizziness.
  • Reports nocturia 2 times per night.
  • Admits recent dietary indiscretion.
  • BP 128/76 mmHg, HR 72 bpm, afebrile.
  • CVS: S1 S2 heard, no murmurs.
  • Chest: Clear.
  • Feet: No ulcers, pulses present, sensations intact.
  • Latest HbA1c (15 May 2024): 7.8%.
  1. Type 2 Diabetes Mellitus – suboptimal control.
  2. Hypertension – controlled.
  3. Hyperlipidaemia – on statin.
  • Increase Metformin from 1g BD to 1.5g BD.
  • Reinforce diet and exercise.
  • Continue Amlodipine, Perindopril, Atorvastatin, Aspirin.
  • Repeat HbA1c, UEC, Lipid profile before next visit.
  • Review in 3 months.
  • Refer to dietitian for medical nutrition therapy.
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Word Count: 139