Heart Health Check (MBS: 699)
**Clinical History**
- Patient's father suffered a myocardial infarction at age 55, and her mother has well-controlled hypertension.
- Patient lives with her partner, works as an accountant, and reports moderate stress levels. She occasionally drinks alcohol but denies illicit drug use. Reports difficulty maintaining a regular exercise routine due to work commitments.
- Currently taking Atorvastatin 20mg daily for dyslipidaemia and Aspirin 100mg daily for primary prevention. Reports good compliance and understanding of medication purpose.
- Patient presented for a routine Heart Health Check. Reports no new cardiovascular symptoms. Discussed previous cholesterol results and blood pressure readings, which have been stable. Patient expressed interest in lifestyle modifications to further reduce her cardiovascular risk.
**Absolute CVD Risk Inputs (as per cvdcheck.org.au)**
Blood pressure: 130/85 mmHg
Total cholesterol: 4.8 mmol/L
HDL cholesterol: 1.2 mmol/L
LDL cholesterol: 2.8 mmol/L
Triglycerides: 1.5 mmol/L
Diabetes: no
Kidney disease: no
Smoking status: never smoked
Aboriginal/Torres Strait Islander or Pacific/Maori heritage: no
Family history of premature CVD (first-degree relative <60 yrs): yes
Other risk modifiers: reports moderate stress and occasional social isolation due to demanding work schedule.
**Lifestyle Goals**
**- Smoking**
"Heart Foundation goal: Quit smoking/avoid second-hand smoke"
My goal: Maintain your non-smoking status and continue to avoid second-hand smoke.
How and When: Continue current practice indefinitely.
**- Healthy Eating**
"Heart Foundation goal: Eat a heart healthy diet (vegetables, fruits, wholegrains, lean proteins, legumes, nuts, reduced-fat dairy, healthy fats, less salt)"
My goal: Increase vegetable intake to 5 servings daily and reduce processed food consumption.
How and When: Will start by planning meals for the week, aiming for 2-3 new vegetable-rich recipes in the next month. To be reviewed at next appointment on 1 November 2024.
**- Physical Activity**
"Heart Foundation goal: ≥30 minutes moderate activity most days"
My goal: Incorporate 30 minutes of brisk walking, 4-5 times per week.
How and When: Will schedule walks during lunch breaks or after work, starting next week. Will track progress using a fitness tracker.
**- Alcohol**
"Heart Foundation goal: ≤10 standard drinks/week, ≤4 on one day"
My goal: Limit alcohol consumption to 2 standard drinks per week.
How and When: Will track intake to ensure adherence, starting immediately.
**- Weight**
"Heart Foundation goal: Maintain healthy weight (waist <94 cm men, <80 cm women)"
My goal: Maintain current healthy weight and aim for a waist circumference below 80 cm.
How and When: Through continued healthy eating and increased physical activity, to be reassessed in 6 months.
**Other Problems**
- Patient expressed concerns about stress management; advised on mindfulness techniques and referred to online resources for stress reduction.
- Discussed importance of regular follow-up for CVD risk factor monitoring.
Heart Health Check (MBS: 699)
**Clinical History**
- [family history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Note family history of relevant conditions.)
- [social history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe social history relevant to cardiovascular risk.)
- [current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Comment on current medication use, including compliance and patient understanding.)
- [current progress notes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Record current progress notes.)
**Absolute CVD Risk Inputs (as per cvdcheck.org.au)**
Blood pressure: [blood pressure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Total cholesterol: [total cholesterol] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
HDL cholesterol: [HDL cholesterol] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
LDL cholesterol: [LDL cholesterol] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Triglycerides: [triglycerides] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Diabetes: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Kidney disease: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Smoking status: [smoking status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Aboriginal/Torres Strait Islander or Pacific/Maori heritage: [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Family history of premature CVD (first-degree relative <60 yrs): [yes/no] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank.)
Other risk modifiers: [other risk modifiers] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain label, and leave blank. E.g. depression, social isolation.)
**Lifestyle Goals**
**- Smoking**
"Heart Foundation goal: Quit smoking/avoid second-hand smoke"
My goal: [patient's smoking goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. If patient is a non-smoker, goal needs to be to "Maintain your non-smoking status and continue to avoid second-hand smoke".)
How and When: [how and when for smoking goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. How and when the patient will achieve this goal.)
**- Healthy Eating**
"Heart Foundation goal: Eat a heart healthy diet (vegetables, fruits, wholegrains, lean proteins, legumes, nuts, reduced-fat dairy, healthy fats, less salt)"
My goal: [patient's eating goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
How and When: [how and when for eating goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. How and when the patient will achieve this goal.)
**- Physical Activity**
"Heart Foundation goal: ≥30 minutes moderate activity most days"
My goal: [patient's activity goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.)
How and When: [how and when for activity goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. How and when the patient will achieve this goal.)
**- Alcohol**
"Heart Foundation goal: ≤10 standard drinks/week, ≤4 on one day"
My goal: [patient's alcohol goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. If patient is a non-drinker, goal needs to be to remain limiting alcohol intake and keeping below National Guidelines.)
How and When: [how and when for alcohol goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. How and when the patient will achieve this goal.)
**- Weight**
"Heart Foundation goal: Maintain healthy weight (waist <94 cm men, <80 cm women)"
My goal: [patient's weight goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. If patient is a healthy weight, goal needs to be to remain at a healthy weight.)
How and When: [how and when for weight goal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. How and when the patient will achieve this goal.)
**Other Problems**
[other problems] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. List any other issues raised. Use as many bullet points as needed to capture all relevant information.)