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A fictional follow-up covering diabetes, blood pressure and cholesterol. Explore the note, suggested codes and a separate copy for the patient.

View visit note PDF View patient summary PDF

Jane Rivera

Fictional patient. September 17, 2026.

Subjective

Established patient seen for follow-up of type 2 diabetes, hypertension and hyperlipidemia. Morning glucose readings are 150-180 mg/dL without hypoglycemia. Taking metformin 1,000 mg twice daily. Home systolic blood pressures are in the 140s while taking lisinopril 10 mg daily. Denies dizziness or chest pain. Taking atorvastatin 20 mg nightly.

Objective

Blood pressure 146/88 mmHg. A1c 7.8%, previously 7.1%. Kidney function described as stable. LDL 92 mg/dL. No additional examination findings documented in this example.

Assessment

1. Type 2 diabetes mellitus with hyperglycemia, above goal.
2. Essential hypertension, above goal.
3. Hyperlipidemia, controlled on current therapy.

Plan

DiabetesContinue metformin 1,000 mg twice daily. Repeat A1c in three months.

HypertensionIncrease lisinopril from 10 mg to 20 mg daily for persistently elevated blood pressure.

After the dose changeCheck kidney function and potassium in one week.

Home monitoringCheck blood pressure at home. Bring readings to follow-up in four weeks.

Return precautionsContact the practice for dizziness or low blood pressure readings.

HyperlipidemiaContinue atorvastatin 20 mg nightly. Repeat lipids in three months.

Routine labsRepeat metabolic panel in three months.

Fictional visit for product demonstration. Example coding requires clinician review.

Suggested codes

E11.65 Type 2 diabetes mellitus with hyperglycemia

I10 Essential hypertension

E78.5 Hyperlipidemia, unspecified

99214 Established outpatient visit, example level for review

Two chronic conditions above goal and prescription medication management support the illustrated moderate-complexity visit. The final code depends on the actual encounter and clinician review.

Read the conversation behind the note

Patient
My sugars have been 150 to 180 in the morning. No low readings. I take metformin 1,000 milligrams twice a day.

Physician
Your A1c is 7.8, up from 7.1. Your home pressures are in the 140s, and today is 146 over 88. Any dizziness or chest pain?

Patient
No. I take lisinopril 10 milligrams daily and atorvastatin 20 milligrams at night.

Physician
Your kidney function is stable, and LDL is 92. Continue the metformin and atorvastatin. Your blood pressure is higher than your target. Increase lisinopril to 20 milligrams daily. This will help lower your blood pressure. Check kidney function and potassium in one week. This is to check how your kidneys and potassium respond to the higher dose. Check blood pressure at home and bring the readings in four weeks. We'll repeat A1c, a metabolic panel and lipids in three months. Call us for dizziness or low blood pressure readings.

After your visit

Your visit summary

Hello Jane, It was wonderful to see you today. Dr. Patel spoke with you about your diabetes, blood pressure and cholesterol. Your blood sugar and blood pressure are higher than the targets set for you.

Your medicines

Dr. Patel increased your lisinopril from 10 mg to 20 mg once a day to help lower your blood pressure. Continue metformin 1,000 mg twice a day for diabetes and atorvastatin 20 mg at night for cholesterol.

Follow-up

In one week, have a blood test to check your kidney function and potassium after the lisinopril dose change. Check your blood pressure at home and bring your readings to your follow-up in four weeks. Repeat your A1c, metabolic panel and cholesterol tests in three months. Call the practice if you feel dizzy or have low blood pressure readings.

Illustrated example View English sample PDF

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