Family Medicine Specialist-Vorlage
Male AWV Note - Cannon
Eine professionelle Family Medicine Specialist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
The Male Annual Wellness Visit (AWV) Note template is designed for family medicine specialists to comprehensively document a male patient's annual health check-up. This template covers key areas such as nutrition, exercise, and screenings for conditions like hypertension, cholesterol, and cancer. It also includes sections for reviewing systems, physical exams, and assessments with detailed plans for preventive care and chronic conditions. This structured format ensures thorough documentation, aiding in effective patient management and follow-up. Ideal for family medicine practitioners, this template streamlines the documentation process, enhancing patient care and communication.
Vorlagenvorschau
Chief Complaint:
- Annual wellness visit
HPI:
1. Hypertension: Patient reports a history of hypertension for the past 5 years. Currently managed with medication, but reports occasional headaches. No recent changes in medication or lifestyle.
2. Hyperlipidemia: Diagnosed 3 years ago, currently on statins. Reports no side effects from medication.
Male AWV
- Nutrition: Patient follows a balanced diet, including fruits, vegetables, and lean proteins.
- Exercise: Engages in moderate exercise, such as walking, for 30 minutes, 5 times a week.
- Falls: No recent falls reported.
- EtOH/Tobacco: Consumes alcohol socially, approximately 2-3 drinks per week. Non-smoker.
- HTN screen: Blood pressure today is 130/85 mmHg.
- Cholesterol: Most recent LDL level is 120 mg/dL.
- 10 year CV risk %: 15%.
- STD screen: No STD screening requested today.
- One time HIV/HBV/HCV screen: Screened for HIV, HBV, and HCV last year, all results negative.
- Skin cancer screening: No concerning lesions noted.
- Depression (PHQ2/9): PHQ9 score of 3, indicating minimal depression.
- Anxiety (GAD2/7): GAD7 score of 2, indicating minimal anxiety.
- Med review: Medication list reviewed and confirmed.
- PSA discussion: PSA testing discussed, patient opted to defer.
- DEXA if at high risk: Not discussed.
- Colon CA screen: Screening colonoscopy discussed, patient agrees to schedule.
- AAA screen: Not discussed.
- Lung CA Screen: Not discussed.
- Advance Care Planning: Advance directive discussed, patient has a living will.
Medical Diagnoses:
1. Hypertension
2. Hyperlipidemia
Specialist Care:
1. Dr. Sarah Lee, Cardiologist
Medications:
1. Lisinopril 10 mg daily
2. Atorvastatin 20 mg daily
Review of Systems
Constitutional: No fever, chills, fatigue, or weight changes.
Eyes: No vision changes, redness, pain, or discharge.
Ears, Nose, Throat: No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia.
Cardiovascular: No chest pain, palpitations, or edema.
Respiratory: No shortness of breath, cough, or wheezing.
Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain.
Genitourinary: No dysuria, hematuria, urinary frequency, or urgency.
Musculoskeletal: No joint pain, stiffness, or swelling.
Skin: No rashes, lesions, or itching.
Neurologic: No headaches, dizziness, numbness, or weakness.
Psychiatric: No anxiety, depression, or mood changes.
Endocrine: No polyuria, polydipsia, or heat/cold intolerance.
Hematologic/Lymphatic: No easy bruising, bleeding, or lymphadenopathy.
Allergic/Immunologic: No allergies, sneezing, or hives.
Physical Exam
Constitutional: Well-nourished, well-developed male in no acute distress.
Vital Signs: Blood pressure 130/85 mmHg, heart rate 72 bpm, respiratory rate 16 breaths/min, temperature 36.8°C.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Labs / Imaging / Diagnostic Tests:
1. Lipid panel from 6 months ago: LDL 120 mg/dL, HDL 50 mg/dL, Triglycerides 150 mg/dL.
Assessment & Plan
1. Preventive Care
Assessment: Patient is due for a colonoscopy as part of routine cancer screening.
Plan:
- Schedule colonoscopy.
- Continue current exercise and diet regimen.
- Follow up in 1 year for next annual wellness visit.
2. Hypertension (I10)
Assessment: Blood pressure is well-controlled on current medication.
Plan:
- Continue Lisinopril 10 mg daily.
- Monitor blood pressure at home.
- Follow up in 6 months for blood pressure check.
3. Hyperlipidemia (E78.5)
Assessment: Lipid levels are stable on current statin therapy.
Plan:
- Continue Atorvastatin 20 mg daily.
- Repeat lipid panel in 1 year.
Procedure Note:
Patient Name: John Doe
Date of Procedure: 1 November 2024
Procedure Performed: None
Indication: N/A
Pre-Procedure Diagnosis: N/A
Post-Procedure Diagnosis: N/A
Details of Procedure:
Consent: N/A
Preparation: N/A
Procedure Steps: N/A
Findings: N/A
Complications: None.
Post-Procedure Care:
Patient tolerated the procedure well.
Post-procedure monitoring: N/A
Follow-up plan: N/A
Medications Administered:
None.
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