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Type 2 diabetes diagnosed 2 weeks ago. Obesity, hypertension, hyperlipidemia. Works as a school bus driver on a split shift (0600-0900 and 1400-1700). Callus on the left heel, no open areas; monofilament sensation intact.2週前診斷為第2型糖尿病。肥胖、高血壓、高血脂。擔任校車司機，採分段班次（0600-0900和1400-1700）。左腳跟有胼胝，無開放性傷口；單股纖維感覺完整。
BP 136/84 mm Hg, HR 78/min, RR 16/min, temperature 36.8 C, BMI 33 kg/m2, SpO2 98% on room air.血壓(BP) 136/84 mm Hg，心率(HR) 78次/分，呼吸速率(RR) 16次/分，體溫 36.8 C，身體質量指數(BMI) 33 kg/m2，室內空氣下血氧飽和度(SpO2) 98%。
HbA1c 8.9% (at diagnosis). Fasting glucose today 168 mg/dL. Creatinine 0.8 mg/dL, eGFR above 90 mL/min/1.73 m2. LDL 142 mg/dL. Urine albumin-to-creatinine ratio 22 mg/g.糖化血色素(HbA1c) 8.9%（診斷時）。今日空腹血糖 168 mg/dL。肌酸酐 0.8 mg/dL，eGFR 高於 90 mL/min/1.73 m2。低密度脂蛋白(LDL) 142 mg/dL。尿液白蛋白與肌酸酐比值 22 mg/g。
Metformin 500 mg PO twice daily with meals. Glipizide 5 mg PO every morning before breakfast. Atorvastatin 20 mg PO daily. Self-monitoring of blood glucose before breakfast and when symptomatic. Diabetes self-management education referral.二甲雙胍 500 mg 口服，每日兩次，隨餐服用。格列吡嗪 5 mg 口服，每日早上早餐前服用。阿托伐他汀 20 mg 口服，每日一次。早餐前和出現症狀時自我監測血糖。轉介糖尿病自我管理衛教。
Client reports 3 loose stools daily since starting metformin, now improving. Reports two episodes this week of shakiness, sweating, and a pounding heart around 1100 on days she skipped breakfast to lose weight; symptoms eased after drinking juice. Does not yet know what these episodes were. Has a glucose meter but has not used it. Walks 10 minutes twice a week.個案報告自開始服用二甲雙胍以來，每天有3次稀便，目前正在改善。本週報告有兩次發作，約在1100，在為了減重而跳過早餐的日子裡出現顫抖、出汗和心悸；喝果汁後症狀緩解。她尚不知道這些發作是什麼。有血糖機但尚未使用。每週走路10分鐘兩次。