HSMC.GPCCMP

Active Problems: Hypertension, Type 2 Diabetes, Asthma Inactive Problems: Appendectomy (2005), Chickenpox (childhood) Allergies: Penicillin (rash) Social History: Lives with wife. Employed as a teacher. Current Medications: Lisinopril 20mg daily, Metformin 500mg twice daily, Salbutamol inhaler as needed. Would a Home Medicine Review (HMR) be beneficial to this patient? No Immunisations: Influenza (annual), COVID-19 (last dose 6 months ago), Pneumonia vaccine (5 years ago). Action: Recommend annual flu vaccine. Recommend COVID-19 booster. Recommend Pneumonia vaccine. Family History: Father had a history of heart disease. Mother has Type 2 Diabetes. Smoking Status: Ex-smoker (quit 10 years ago). Action: N/A Alcohol Use: Drinks alcohol 2-3 days per week, 2-3 standard drinks per session. Action: Advised to reduce alcohol consumption to no more than 4 standard drinks on any one occasion. Health and Lifestyle Diet: Eats a balanced diet with plenty of fruit and vegetables. Eats 3 serves of fruit, 4 serves of vegetables, 2 serves of dairy, drinks 2 litres of water and eats 2 serves of protein per day. Exercise: Walks for 30 minutes, 3 times per week. Mental Health: Reports feeling stressed due to work. No current mental health services or medications. Sleep: Reports difficulty falling asleep. Feels tired during the day. Action: Advised to increase exercise to 150 minutes of moderate intensity exercise per week. Encouraged to seek supports for mental health. Encouraged to look into sleep hygiene to manage poor sleep. Screening: Cervical Screening Test: N/A FOBT: 12/06/2023. Next test due 12/06/2025 Pathology: Last blood tests 10/10/2024. Next blood tests due 10/10/2025 Mammogram: N/A PSA: N/A DEXA scan: N/A CVR: 10% AUSDRisk: 15 Advanced Care Directive: No Follow up appointment for review of GPCCMP in 3-months: Yes, with doctor, face-to-face. GP Chronic Condition Management Plan (GPCCMP): 1. Hypertension - Patient Actions/ Lifestyle Goals: Reduce sodium intake, increase exercise to 150 minutes per week, and monitor blood pressure at home. - Required Treatments and services: Continue Lisinopril 20mg daily. Referral to a dietician for dietary advice. Referral to a physiotherapist for exercise advice. - Multidisciplinary Care Providers: Referral to a dietician and physiotherapist. 2. Type 2 Diabetes - Patient Actions/ Lifestyle Goals: Follow a low-GI diet, monitor blood glucose levels daily, and attend diabetes education sessions. - Required Treatments and services: Continue Metformin 500mg twice daily. Referral to a diabetes educator. Referral to a podiatrist. - Multidisciplinary Care Providers: Referral to a diabetes educator and podiatrist. 3. Asthma - Patient Actions/ Lifestyle Goals: Use Salbutamol inhaler as needed, avoid asthma triggers, and attend regular asthma reviews. - Required Treatments and services: Continue Salbutamol inhaler as needed. Referral to a respiratory specialist. - Multidisciplinary Care Providers: Referral to a respiratory specialist. -- GPCCMP Process Documentation: - Patient Consent and Agreement: Patient verbally consented to the plan's preparation. - Offer of Plan Copy to Patient/Carer: Copy of plan offered to patient and accepted. - Plan Added to Medical Records: Plan to be uploaded to patient's medical records. - Progress towards Goals (for Review): N/A - Updates to GPMP (for Review): N/A - Information from Multidisciplinary Team (for Review): N/A