Chronic Care Management Note

Subjective

Arthur Pendelton (DOB: 14/05/1952, MRN: 492-817-33) is a 71-year-old male presenting via telephone on 15/10/2023 at 14:15 CST for monthly Chronic Care Management (CCM) follow-up regarding T2DM, essential HTN, and bilateral knee OA.

Objective

Type 2 Diabetes Mellitus (T2DM) Patient reports checking fasting blood glucose (FBG) 4 times weekly; values range 110–135 mg/dL. Asymptomatic; denies polyuria, polydipsia, or hypoglycemic episodes. Denies blurred vision or paresthesias.

Essential Hypertension (HTN) Home BP log averages 128/78 mmHg over the past 2 weeks. Well-controlled; 100% adherent to lisinopril 20 mg PO daily and low-sodium diet. Denies chest pain, SOB, or lower extremity edema.

Osteoarthritis (OA) of bilateral knees Reports intermittent aching pain in bilateral knees, worse in the mornings. Mild to moderate (4/10 on VAS), resolving within 30 minutes of ambulation. Applying diclofenac (Voltaren®) 1% topical gel QID PRN and performing daily low-impact stretching. Denies joint locking, catching, or acute swelling.

Physical Exam

Deferred due to audio-only telephone encounter format.

Assessment and Plan

Physical Exam

Deferred due to audio-only telephone encounter format.

Assessment / Plan

1. T2DM: At goal (most recent HbA1c 6.8%). Continue metformin (Glucophage®) 1,000 mg PO BID. Goal FBG 80–130 mg/dL.
2. Essential HTN: At goal (< 130/80 mmHg). Continue lisinopril (Prinivil®) 20 mg PO daily. Maintain daily home BP logs.
3. Bilateral knee OA: Stable. Continue diclofenac 1% gel topically QID PRN and home exercise program. Avoid oral NSAIDs given HTN and renal protection goals.

Discussion Notes

Chart review (10 mins) and interactive telephone call (15 mins) completed; total CCM time 25 minutes. Patient is stable, ambulatory, and lives at home with supportive spouse who assists with meal prep. Actively engaged in self-monitoring (BP and glucose logs) and receptive to lifestyle coaching. Denies recent ED visits, hospitalizations, or falls over the past 30 days. Adherent to all prescribed regimens; 90-day refills confirmed at local pharmacy with no barriers to access. Reviewed labs from 02/10/2023: HbA1c 6.8%, eGFR 72 mL/min/1.73m², K 4.2 mmol/L, urine microalbumin/creatinine ratio 18 mg/g. Annual dilated eye exam scheduled with Ophthalmology for 12/11/2023. In-clinic PCP follow-up scheduled for 18/01/2024 at 09:30 CST; spouse will provide transportation. Reviewed hypoglycemic/hyperglycemic red flags and signs of hypertensive urgency. Instructed to call clinic for FBG > 250 mg/dL, BP > 160/100 mmHg, or worsening joint pain. Next CCM call in 30 days.