Visit Notes
ENCOUNTER NOTE
Patient: Maria Gonzalez | DOB: 03/15/1968
DOS: 01/15/2025 | Provider: Dr. Sarah Chen, MD
CHIEF COMPLAINT:
Follow-up diabetes management. Increased fatigue, ankle swelling x3 weeks.
HISTORY:
T2DM diagnosed 2012. Metformin 1000mg BID, Lisinopril 20mg. Last A1C: 8.2%. CKD Stage 3a, eGFR 48.
EXAM:
BP 148/92, Weight 187 (up 4 lbs), bilateral ankle edema 1+, decreased monofilament sensation bilateral feet.
ASSESSMENT:
1. T2DM with diabetic CKD — poorly controlled
2. Hypertension — not at goal
3. Peripheral neuropathy — stable
PLAN:
Increase Metformin to 1500mg, add Jardiance. Adjust Lisinopril to 40mg. Nephrology referral. CMP + A1C in 4 weeks. Dietary counseling 30 min.
Time: 35 min, >50% counseling/coordination