Annual Health Check

Consent for use of AI notetaking obtained Presents for Annual Health Check Significant life events/changes in last year: - Patient reports the recent loss of her husband, which has significantly impacted her emotional well-being. She has also moved to a new apartment. Current Issues: - Patient reports feeling low in mood and experiencing some social isolation since the death of her husband. She also reports occasional headaches. Health and/or life goals in next 12 months: - Patient would like to improve her mood and increase her social activities. She is also considering joining a walking group. Relevant Previous Medical History: - Hypertension, managed with medication. Previous history of a fractured wrist. Relevant Family History and risk factors for chronic disease: - Father had a history of heart disease. Mother had type 2 diabetes. Medications: - Lisinopril 20mg daily, Paracetamol as needed for headaches. Allergies: - No known allergies. Relevant Social History: - Patient is a widow. She lives alone. She is a non-smoker and drinks alcohol occasionally. Diet, Exercise, Sleep and Substances: - Patient reports a balanced diet. She does not exercise regularly. She sleeps approximately 7 hours per night. She drinks alcohol socially. Mental Health and Well-being: - Patient reports low mood and feelings of loneliness. She denies any suicidal ideation. She is experiencing grief following the death of her husband. Immunisations: - Up to date with influenza and COVID-19 vaccinations. Requires pneumococcal vaccination. Investigations and screening: - Blood pressure check performed today. Routine blood tests due. Mammogram due in 6 months. Other care providers: - Attends a local bereavement group once a week. - Currently under a chronic disease management plan for hypertension. Physical examination: - Blood pressure: 130/80 mmHg, Heart rate: 72 bpm, Respiratory rate: 16 breaths/min, Temperature: 37°C, Oxygen saturation: 98% on room air. - General appearance: Alert and oriented, appears her stated age. - Document findings from physical examination: Cardiovascular: Regular rhythm, no murmurs. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender. Assessment: - Summarize health status, including any diagnoses or conditions: Hypertension, grief, low mood. - Mention any risk factors identified: Family history of heart disease and type 2 diabetes. - For each chronic condition, list management goals and actions for the patient, treatment and services the patient will need, arrangements for providing the treatment and services (including information on other health providers), and when review is needed: Hypertension: Continue Lisinopril 20mg daily. Monitor blood pressure regularly. Review in 3 months. Grief/Low mood: Encourage participation in bereavement group. Consider referral to a counsellor. Review in 1 month. Plan: - Outline recommended screenings or tests: Routine blood tests, mammogram in 6 months, pneumococcal vaccination. - Describe lifestyle or dietary recommendations: Encourage regular exercise, healthy diet, and social interaction. - Mention follow-up appointments or referrals: Follow-up appointment in 1 month to review mood and grief. Referral to a counsellor. - Document any prescribed medications or changes to current medications: No changes to current medications. - Specifically document responses to any questions asked and advice given about planned overseas travel, Vaccination status, Contraception/ Sexual health, pregnancy planning, Eye checks, Dental checks, Mammograms, bone health and bowel screening: Discussed the importance of maintaining current vaccinations. Advised on the importance of regular dental and eye checks. Discussed the importance of bowel screening.