Note Report Sample:
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SUBJECTIVE: This is a 32-year-old gentleman who came in for reevaluation of diabetes mellitus. He was started on Metformin 500 mg t.i.d last week and so far he has tolerated the medication well. He stated he is feeling a lot better. He has no more polyuria, no polydipsia, and he has more energy.
LABORATORY REVIEW: He had laboratory workup done. It showed glucose of 241, BUN and creatinine is in good range, total bilirubin is 1.2, AST is 49, ALT 135, total cholesterol is 216, triglyceride 180, and hemoglobin A1c is 11.4. He does not have any microalbuminuria.
PHYSICAL EXAMINATION: Blood pressure is 130/70. Respiratory is 16. Pulse is 68. Weight is 242 pounds. Temperature is 98.1 degrees. He is alert and oriented x 3.
ABDOMEN: Flat, soft, and nontender. He has no organomegaly or no jaundice noted.
ASSESSMENT AND PLAN:
1. Diabetes mellitus. I encourage diet and exercise. I also counseled him about decreasing his carbohydrate intake.
2. I will check for hepatitis B and C profile and do an abdominal ultrasound.
3. Patient is to return after his blood test is completed.