Annual Health Check

Clinician Specialty: General Practitioner Patient attends for their annual health check. Last health check was 1 November 2023. Verbal informed consent obtained for use of Heidi AI transcription programme during consultation. Current Health Concerns: * Fatigue and low energy for the past 3 months, impacting daily activities. * Occasional headaches, typically once or twice a week, described as tension-type. * Mild digestive discomfort after certain meals, specifically bloating. Past Medical/Surgical History: * Appendectomy (2005) * Glandular fever (2010) * No major chronic illnesses. Current Medications and Drug allergies: * Multivitamin (daily) * Fish Oil (daily) * No known drug allergies. Family History: * Mother: Hypertension (diagnosed at 55) * Father: Type 2 Diabetes (diagnosed at 60) * Maternal Grandmother: Osteoarthritis Social History: * Occupation: Accountant (office-based) * Children: Two (aged 8 and 12) * Pets: One cat * Smoking: Non-smoker * Alcohol: 2-3 units per week * Exercise: Walks 3-4 times a week for 30 minutes, occasional yoga. * Diet: Generally balanced, occasional takeaways. * Caffeine: 1-2 cups of coffee daily. * Illicit drugs: None. Screenings: * Cervical screening: Up to date (last one 1 November 2022). * Mammogram: Due (patient is 45). * Bowel cancer screening: Due (patient is 45). Vaccinations: * Tetanus/Diphtheria/Pertussis: Up to date (last one 1 November 2019). * Influenza: Due (annual). * COVID-19: Up to date. Systems Review: * Eyes / Vision: Occasional blurring at end of day, wears glasses for reading. Last eye check 1 November 2023, no concerns raised. * Dental Health: No current dental problems. Last dental check 1 November 2024. * Ears, Nose and Throat Systems: No hearing issues, occasional mild tinnitus in left ear, no history of ear infections, good sense of smell, no nosebleeds, no difficulty swallowing, occasional mild sore throat in winter, no sinus pain. * Cardiovascular System: No chest pain or palpitations. No history of blood pressure issues. No ankle swelling. * Respiratory System: No chronic cough, wheeze, or shortness of breath. Occasional seasonal allergy symptoms. * Abdominal System: Mild bloating as mentioned in current concerns, no significant abdominal pain, no indigestion, regular bowel habits, no blood in stool. * Neurological Systems: Headaches as mentioned, no dizziness or fainting. No numbness or weakness. Memory is good. * Breast and Gynae: No breast pain or lumps. Regular menstrual cycle (28 days, 5 days bleeding). No pain on intercourse, no vaginal infections or discharge. * Urinary Systems: No history of urine infections or bladder pain. No stress or urge incontinence. * Musculoskeletal Systems: Occasional mild lower back stiffness, no significant joint pains or myalgia. * Skin: No new moles or concerning lesions. No rashes. * Mental Health: Reports generally good mood, some stress related to work, sleep is fair but sometimes disturbed by children. Examination: * Chaperone offered and declined. * Weight: 70 kg * Height: 165 cm * Blood Pressure: 120/75 mmHg * Waist Circumference: 80 cm * Urinalysis: Normal * ECG findings: Normal sinus rhythm Plan: * Advise on gentle exercise for lower back stiffness. * Recommend dietary review for bloating, suggest a food diary for 2 weeks. * Refer for mammogram and bowel cancer screening. * Discuss annual influenza vaccination. * Follow-up in 6 months or sooner if symptoms worsen.