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CLINICAL OUTPATIENT ENCOUNTER NOTE
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PATIENT DEMOGRAPHICS & VISIT METRICS:
Patient Name:       Miller, Robert E.
MRN:                7104928
DOB:                11/03/1966 (Age: 59)
Sex:                Male
Date of Service:    09/18/2026
Encounter Type:     Outpatient Primary Care / Comprehensive Chronic Follow-up
Attending Provider: Dr. Sarah Vance, MD
Facility:           Valley Health Family Medicine Clinic

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SUBJECTIVE
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CHIEF COMPLAINT:
"Quarterly diabetes follow-up and refills, plus my heartburn has been acting up at night."

HISTORY OF PRESENT ILLNESS (HPI):
Robert Miller is a 59-year-old male with a 6-year history of Type 2 Diabetes Mellitus 
(non-insulin dependent) and moderate Gastroesophageal Reflux Disease (GERD) 
presenting for scheduled quarterly management.

1. Type 2 Diabetes Mellitus:
   * Self-Monitored Blood Glucose (SMBG): Fasting glucose readings over the past 
     90 days range between 110 and 145 mg/dL; postprandial levels generally remain 
     under 170 mg/dL.
   * Adherence: Reports complete compliance with Metformin 1000 mg twice daily 
     and Empagliflozin 10 mg daily. Denies GI intolerance to metformin.
   * Symptoms: Denies polyuria, polydipsia, polyphagia, blurry vision, or episodes 
     of hypoglycemia (no shakiness, diaphoresis, or palpitations).
   * Microvascular screening: Denies lower extremity paresthesias, numbness, 
     burning pain, or non-healing foot sores. Last dilated eye exam performed 
     4 months ago with no reported retinopathy.

2. Gastroesophageal Reflux Disease (GERD):
   * Reports increased nocturnal acid reflux and retrosternal burning 3-4 nights 
     per week over the past month.
   * Associated with late-evening meals and recent dietary indiscretion.
   * Denies dysphagia, odynophagia, unintentional weight loss, hematemesis, or melena.
   * Currently taking OTC Famotidine 20 mg PRN with incomplete symptom relief.

CURRENT MEDICATIONS:
1. Metformin HCl Extended-Release 1000 mg PO; take 1 tablet BID with meals.
2. Empagliflozin (Jardiance) 10 mg PO; take 1 tablet once daily in the morning.
3. Atorvastatin 20 mg PO; take 1 tablet once daily at bedtime.
4. Famotidine 20 mg PO; take 1 tablet PRN heartburn (frequency: ~4 times weekly).

ALLERGIES:
* No Known Drug Allergies (NKDA).

PAST MEDICAL HISTORY (PMH):
* Type 2 Diabetes Mellitus without acute complications (ICD-10: E11.9)
* Hyperlipidemia, primary (ICD-10: E78.00)
* GERD without esophagitis (ICD-10: K21.9)

PAST SURGICAL HISTORY (PSH):
* Right inguinal hernia repair (open), 2018.

SOCIAL HISTORY:
* Tobacco: Former smoker (15 pack-year history; quit 10 years ago).
* Alcohol: 1 beer on weekends; denies heavy or binge drinking.
* Diet: Reports difficulty limiting refined carbohydrates during work lunches.
* Exercise: Walks 20-30 minutes twice a week.

REVIEW OF SYSTEMS (ROS):
* General: No fever, chills, night sweats, or fatigue.
* HEENT: No visual changes, nasal congestion, or sore throat.
* Cardiovascular: No chest pressure, palpitations, or orthopnea.
* Respiratory: No cough, dyspnea, or wheezing.
* Gastrointestinal: Positive for retrosternal pyrosis as noted in HPI; denies nausea, vomiting, abdominal tenderness, or hematochezia.
* Genitourinary: Denies dysuria, hematuria, or daytime frequency.
* Extremities: No edema.
* Neurologic: Intact sensation bilaterally; no focal deficits or gait instability.

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OBJECTIVE
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VITAL SIGNS:
* Blood Pressure:       124/78 mmHg (Left arm, regular adult cuff, seated)
* Heart Rate:           68 bpm (regular rhythm)
* Respiratory Rate:     14 breaths/min
* Temperature:          98.2 °F (36.8 °C, oral)
* SpO2:                 98% on ambient air
* Height:               5 ft 10 in (177.8 cm)
* Weight:               198.0 lbs (89.8 kg)
* BMI:                  28.4 kg/m²

PHYSICAL EXAMINATION:
* General: Well-developed, overweight male in no acute distress. Alert, cooperative.
* Head/Neck: Normocephalic, atraumatic. Mucous membranes moist. No thyromegaly or JVD.
* Cardiovascular: Normal rate, regular rhythm. S1 and S2 normal. No murmurs, gallops, or rubs.
* Pulmonary: Clear to auscultation bilaterally. Breath sounds vesicular throughout.
* Abdomen: Soft, non-distended. Mild epigastric tenderness to deep palpation without guarding or rebound. Normoactive bowel sounds. No masses or organomegaly.
* Extremities: Warm, well-perfused. No pretibial or pedal edema. Posterior tibial and dorsalis pedis pulses 2+ bilaterally.
* Diabetic Foot Exam:
  * Inspection: Skin intact bilaterally. No erythema, calluses, maceration, ulcerations, or nail dystrophies.
  * Neurologic: Normal sensation to 10g Semmes-Weinstein monofilament testing across 10 plantar sites bilaterally.
  * Vibration: Intact bilaterally at the hallux.

POINT-OF-CARE & RECENT LAB RESULTS:
* POC Hemoglobin A1c (In-clinic today): 7.1% (Previous: 7.4% 6 months prior)
* POC Urine Microalbumin/Creatinine Ratio: 18 mcg/mg (Normal: <30 mcg/mg)
* Fasting BMP (09/10/2026):
  * Sodium: 139 mEq/L
  * Potassium: 4.1 mEq/L
  * BUN: 16 mg/dL
  * Creatinine: 0.92 mg/dL
  * eGFR: >90 mL/min/1.73m²
* Fasting Lipid Panel (09/10/2026):
  * Total Cholesterol: 162 mg/dL
  * Triglycerides: 148 mg/dL
  * HDL: 46 mg/dL
  * LDL: 86 mg/dL

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ASSESSMENT & PLAN
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1. Type 2 Diabetes Mellitus without Complications (E11.9)
   * Status: Glycemic control improving (A1c down from 7.4% to 7.1%, approaching patient goal of <7.0%). Renal function stable, no microalbuminuria, diabetic foot exam normal.
   * Plan:
     - Continue Metformin ER 1000 mg PO BID.
     - Continue Empagliflozin 10 mg PO daily.
     - Continue daily self-foot inspections.
     - Nutrition referral ordered for medical nutrition therapy to address carbohydrate counting during workdays.

2. Gastroesophageal Reflux Disease (GERD) without Esophagitis (K21.9)
   * Status: Uncontrolled on intermittent H2-receptor antagonist; symptoms aggravated by late meal timing.
   * Plan:
     - Discontinue PRN famotidine.
     - Start Omeprazole 20 mg PO once daily, 30-60 minutes before breakfast for an 8-week trial course.
     - Lifestyle modifications reviewed: avoid recumbency within 3 hours of meals, elevate head of bed 6 inches, and limit trigger foods (caffeine, high-fat evening meals).
     - Instructed to return or contact clinic if dysphagia, food impaction, or involuntary weight loss develops.

3. Primary Hyperlipidemia (E78.00)
   * Status: Well-controlled on moderate-intensity statin therapy (LDL 86 mg/dL).
   * Plan:
     - Continue Atorvastatin 20 mg PO daily at bedtime.
     - Repeat lipid panel in 12 months.

4. Health Maintenance & Prevention:
   * Administered Pneumococcal conjugate vaccine (PCV20, Lot #NV104, Right Deltoid) as indicated for adults with diabetes.
   * Annual dilated retinal exam up to date.

FOLLOW-UP:
* Return to clinic in 3 months for repeat A1c and clinical re-evaluation of reflux symptoms.
* Red flags discussed: seek immediate medical attention for chest pain radiating to arm/jaw, acute shortness of breath, dark tarry stools, or persistent vomiting.

Total visit duration: 30 minutes.

Provider Signature:
Sarah Vance, MD
Internal Medicine / Primary Care
NPI: 1498230192
Date: 09/18/2026